Healthcare Provider Details

I. General information

NPI: 1497229603
Provider Name (Legal Business Name): LAGS SPINE AND SPORTSCARE MEDICAL CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 Q ST STE 105
BAKERSFIELD CA
93301-1645
US

IV. Provider business mailing address

218 N I ST
LOMPOC CA
93436-0909
US

V. Phone/Fax

Practice location:
  • Phone: 661-432-1451
  • Fax: 661-489-5040
Mailing address:
  • Phone: 805-736-7886
  • Fax: 805-736-7867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY D'AMATO
Title or Position: CONTRACTING MANAGER
Credential:
Phone: 805-264-3388