1528463718 NPI number — BACKBONE SURGICAL SUPPORT, LLC

Table of content: (NPI 1528463718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528463718 NPI number — BACKBONE SURGICAL SUPPORT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACKBONE SURGICAL SUPPORT, 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:
1528463718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4582 KINGWOOD DRIVE
Provider Second Line Business Mailing Address:
STE 187
Provider Business Mailing Address City Name:
KINGWOOD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-269-4564
Provider Business Mailing Address Fax Number:
888-426-6435

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4582 KINGWOOD DR
Provider Second Line Business Practice Location Address:
STE 187
Provider Business Practice Location Address City Name:
KINGWOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77345-2639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-269-4564
Provider Business Practice Location Address Fax Number:
888-426-6435
Provider Enumeration Date:
10/30/2014

Additional Information

Authorized Official

Authorized Official Last Name:
VADHEIM
Authorized Official First Name:
COLIN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGEING MEMBER
Authorized Official Telephone Number:
713-231-7720

Provider Taxonomy Codes

  • Taxonomy code: 246ZC0007X , 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)





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