Healthcare Provider Details

I. General information

NPI: 1558846949
Provider Name (Legal Business Name): SPIRIT MEDICAL MANAGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 S FAIR OAKS AVE
PASADENA CA
91105-2606
US

IV. Provider business mailing address

1510 S CENTRAL AVE STE 120
GLENDALE CA
91204-2576
US

V. Phone/Fax

Practice location:
  • Phone: 818-281-9004
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: KAY BLAINE
Title or Position: CFO
Credential:
Phone: 818-281-9004