Healthcare Provider Details

I. General information

NPI: 1770589418
Provider Name (Legal Business Name): EAST BAY SPINE SPECIALISTS INC A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5725 W LAS POSITAS BLVD STE 200
PLEASANTON CA
94588-4007
US

IV. Provider business mailing address

696 SAN RAMON VALLEY BLVD # 372
DANVILLE CA
94526-4022
US

V. Phone/Fax

Practice location:
  • Phone: 925-469-3120
  • Fax: 925-924-1769
Mailing address:
  • Phone: 925-469-3120
  • Fax: 925-924-1769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberGROUP
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberGROUP
License Number StateCA

VIII. Authorized Official

Name: CHIP KRULL
Title or Position: COO
Credential:
Phone: 925-469-3120