Healthcare Provider Details

I. General information

NPI: 1902274509
Provider Name (Legal Business Name): SPINE LINK MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10808 FOOTHILL BLVD SUITE 160-409
RANCHO CUCAMONGA CA
91730-3889
US

IV. Provider business mailing address

10808 FOOTHILL BLVD SUITE 160-409
RANCHO CUCAMONGA CA
91730-3889
US

V. Phone/Fax

Practice location:
  • Phone: 909-373-4633
  • Fax: 909-980-1378
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246YC3302X
TaxonomyPhysician Office Based Coding Specialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. JOE WRIGHT
Title or Position: CEO
Credential:
Phone: 909-373-4633