Healthcare Provider Details

I. General information

NPI: 1639214349
Provider Name (Legal Business Name): US SPINE & SPORT FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3444 KEARNY VILLA RD 205
SAN DIEGO CA
92123-1959
US

IV. Provider business mailing address

3444 KEARNY VILLA RD 200
SAN DIEGO CA
92123-1959
US

V. Phone/Fax

Practice location:
  • Phone: 858-573-9368
  • Fax: 858-874-0582
Mailing address:
  • Phone: 888-208-8526
  • Fax: 858-751-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: VERT MOONEY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 888-208-8526