Healthcare Provider Details

I. General information

NPI: 1750789053
Provider Name (Legal Business Name): SPINE & NERVE DIAGNOSTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2014
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 DUCKHORN DR STE 200
SACRAMENTO CA
95834-2590
US

IV. Provider business mailing address

1528 EUREKA RD STE 103
ROSEVILLE CA
95661-3047
US

V. Phone/Fax

Practice location:
  • Phone: 916-419-9900
  • Fax: 916-419-9699
Mailing address:
  • Phone: 916-772-5325
  • Fax: 916-772-6333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number00A63460
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number00A83749
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number00A83749
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number00A63460
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number00A63460
License Number StateCA

VIII. Authorized Official

Name: VINAY REDDY
Title or Position: MD/PRESIDENT
Credential: MD
Phone: 916-722-5325