1205016383 NPI number — OPTIMAL SPINE INC

Table of content: (NPI 1205016383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205016383 NPI number — OPTIMAL SPINE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMAL SPINE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205016383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEWARTSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17363-4003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-993-5388
Provider Business Mailing Address Fax Number:
717-993-5388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STEWARTSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17363-4003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-993-5388
Provider Business Practice Location Address Fax Number:
717-993-5388
Provider Enumeration Date:
11/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WISTORT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
JAY-BRADLEY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
717-993-5388

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC4408L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 52578001 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com