Healthcare Provider Details

I. General information

NPI: 1972955128
Provider Name (Legal Business Name): SAN DIEGO SPINE & PAIN CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13029 POMERADO RD SUITE C
POWAY CA
92064-4246
US

IV. Provider business mailing address

13029 POMERADO RD SUITE C
POWAY CA
92064-4246
US

V. Phone/Fax

Practice location:
  • Phone: 858-312-5016
  • Fax: 858-312-5018
Mailing address:
  • Phone: 858-312-5016
  • Fax: 858-312-5018

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: LANETTE V. BUMGARDNER
Title or Position: OWNER/CEO
Credential:
Phone: 310-594-5640