Healthcare Provider Details

I. General information

NPI: 1760606537
Provider Name (Legal Business Name): CENTER FOR INTERVENTIONAL SPINE, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 03/31/2023
Certification Date: 03/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 ARDEN WAY STE 301
SACRAMENTO CA
95825-2464
US

IV. Provider business mailing address

2424 ARDEN WAY STE 301
SACRAMENTO CA
95825-2464
US

V. Phone/Fax

Practice location:
  • Phone: 916-977-0741
  • Fax: 916-977-0547
Mailing address:
  • Phone: 916-977-0741
  • Fax: 916-977-0547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA60900
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA60900
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberA60900
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: CARL HYUN-GEOL SHIN
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 916-977-0741