MEDICARE: SPINE INFORMATICS AUSTIN, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1417476912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE INFORMATICS AUSTIN, LLC

Provider Business Mailing Address
First Line	:	3202 SWEET AUTUMN CV
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78735-1524
Country	:	US
Telephone Number	:	512-913-1834
Fax Number	:	512-537-1537

Provider Business Practice Location Address
First Line	:	110 WILD BASIN RD STE 250
Second Line	:
City	:	WEST LAKE HILLS
State	:	TX
Zip	:	78746-3352
Country	:	US
Telephone Number	:	512-531-9912
Fax Number	:	512-537-1537

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MR. GERALD LEE DEVRIES JR.
Credential	:	INVESTOR
Telephone Number	:	512-913-1834

Provider Enumeration Date	:	09/15/2017
Last Update Date	:	09/15/2017

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