1487175881 NPI number — INNOVATIVE PHYSIATRY SPINE CLINIC, LLC

Table of content: (NPI 1487175881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487175881 NPI number — INNOVATIVE PHYSIATRY SPINE CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE PHYSIATRY SPINE CLINIC, LLC
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:
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:
1487175881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 385
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONTE VEDRA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32004-0385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-671-0288
Provider Business Mailing Address Fax Number:
904-508-0674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 DURBIN STATION CT STE 601
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST JOHNS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32259-9370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-671-0288
Provider Business Practice Location Address Fax Number:
904-508-0674
Provider Enumeration Date:
07/06/2017

Additional Information

Authorized Official

Authorized Official Last Name:
LIM
Authorized Official First Name:
SECK
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
904-671-0288

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  OS12124 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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