Healthcare Provider Details

I. General information

NPI: 1932851177
Provider Name (Legal Business Name): SPINEZONE MEDICAL FITNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 09/15/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11838 BERNARDO PLAZA CT STE 101
SAN DIEGO CA
92128-2414
US

IV. Provider business mailing address

7525 METROPOLITAN DR STE 306
SAN DIEGO CA
92108-4404
US

V. Phone/Fax

Practice location:
  • Phone: 844-316-7979
  • Fax: 866-813-1235
Mailing address:
  • Phone: 844-316-7979
  • Fax: 866-813-1235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: IVANIA CASTLE
Title or Position: BILLING MANAGER/ CREDENTIALING
Credential:
Phone: 619-432-4634