Healthcare Provider Details

I. General information

NPI: 1043799018
Provider Name (Legal Business Name): LAGS SPINE AND SPORTSCARE MEDICAL CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 PRECISSI LN STE A
STOCKTON CA
95207-6240
US

IV. Provider business mailing address

218 NORTH I STREET
LOMPOC CA
93436
US

V. Phone/Fax

Practice location:
  • Phone: 209-425-3815
  • Fax:
Mailing address:
  • Phone: 209-425-3815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: SARA SHOWERS
Title or Position: MEDICAL BILLING SPECIALIST LEAD
Credential:
Phone: 805-928-7361