Healthcare Provider Details

I. General information

NPI: 1538950878
Provider Name (Legal Business Name): SPINAL IQ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7131 YORKTOWN AVE # 1069
HUNTINGTON BEACH CA
92648-2464
US

IV. Provider business mailing address

7131 YORKTOWN AVE # 1069
HUNTINGTON BEACH CA
92648-2464
US

V. Phone/Fax

Practice location:
  • Phone: 310-463-3619
  • Fax:
Mailing address:
  • Phone: 310-463-3619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: TONYA GILLIAM
Title or Position: VP OF BILLING
Credential:
Phone: 972-632-6877