Healthcare Provider Details

I. General information

NPI: 1912460874
Provider Name (Legal Business Name): LAGS SPINE AND SPORTSCARE MEDICAL CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 21ST AVE W STE 3
BRADENTON FL
34209-5605
US

IV. Provider business mailing address

218 N I ST
LOMPOC CA
93436-0909
US

V. Phone/Fax

Practice location:
  • Phone: 805-928-7361
  • Fax:
Mailing address:
  • Phone:
  • 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: AMY DAMATO
Title or Position: CONTRACTS MANAGER
Credential:
Phone: 805-264-3388