Healthcare Provider Details

I. General information

NPI: 1982613782
Provider Name (Legal Business Name): HEALTHSTAR SPINAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 FRIST BLVD SUITE 2
FORT PIERCE FL
34950-4839
US

IV. Provider business mailing address

1611 ORANGE AVE
FORT PIERCE FL
34950-6816
US

V. Phone/Fax

Practice location:
  • Phone: 772-465-1500
  • Fax: 772-465-0050
Mailing address:
  • Phone: 772-465-1500
  • Fax: 772-465-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberHCCR3622
License Number StateFL

VIII. Authorized Official

Name: MRS. JIMA L. JONES
Title or Position: VICE PRESIDENT
Credential: RDMS,RVT,RDCS
Phone: 772-465-1500