1366614653 NPI number — MV SPINE AND JOINT, P.A.

Table of content: (NPI 1366614653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366614653 NPI number — MV SPINE AND JOINT, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MV SPINE AND JOINT, P.A.
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:
1366614653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 MIDWAY CRST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78258-4335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-337-6688
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
703 US HIGHWAY 90 E
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
CASTROVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78009-5246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-931-2211
Provider Business Practice Location Address Fax Number:
830-538-3778
Provider Enumeration Date:
03/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DOVER
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
501-337-6688

Provider Taxonomy Codes

  • Taxonomy code: 251T00000X , with the licence number:  1507 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 12929 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 154829718 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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