Healthcare Provider Details

I. General information

NPI: 1932598760
Provider Name (Legal Business Name): SPINE & SPORTS SURGICAL CENTER, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2015
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W LA VETA AVE 300
ORANGE CA
92868-4231
US

IV. Provider business mailing address

1120 W LA VETA AVE # 330
ORANGE CA
92868-4231
US

V. Phone/Fax

Practice location:
  • Phone: 714-598-1745
  • Fax: 714-941-9539
Mailing address:
  • Phone: 714-598-1745
  • Fax: 714-941-9539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GREGORY D CARLSON
Title or Position: PRESIDENT
Credential: MD
Phone: 714-598-1745