Healthcare Provider Details

I. General information

NPI: 1699326744
Provider Name (Legal Business Name): SPINE CENTER OF FL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 SE 9TH PL
CAPE CORAL FL
33990-3003
US

IV. Provider business mailing address

11921 ROCKVILLE PIKE STE 505
ROCKVILLE MD
20852-2758
US

V. Phone/Fax

Practice location:
  • Phone: 239-333-1177
  • Fax: 239-333-1169
Mailing address:
  • Phone: 703-789-1929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS W WISOR
Title or Position: OFFICER
Credential: MD
Phone: 703-927-5772