Healthcare Provider Details

I. General information

NPI: 1386855898
Provider Name (Legal Business Name): PACIFIC SPINE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 E GRAND AVE SUITE 1-2
ESCONDIDO CA
92025-3313
US

IV. Provider business mailing address

355 E GRAND AVE SUITE 1-2
ESCONDIDO CA
92025-3313
US

V. Phone/Fax

Practice location:
  • Phone: 760-489-2379
  • Fax: 760-489-8106
Mailing address:
  • Phone: 760-489-2379
  • Fax: 760-489-8106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberA30927
License Number StateCA

VIII. Authorized Official

Name: DR. LAURENCE MERCER MCKINLEY
Title or Position: OWNER
Credential: MD
Phone: 760-489-2379