Healthcare Provider Details

I. General information

NPI: 1326462417
Provider Name (Legal Business Name): ORTHOPAEDIC AND SPINE MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 02/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 W OAK ST
KISSIMMEE FL
34741-6627
US

IV. Provider business mailing address

435 W OAK ST
KISSIMMEE FL
34741-6627
US

V. Phone/Fax

Practice location:
  • Phone: 407-530-4734
  • Fax:
Mailing address:
  • Phone: 407-530-4734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberCH8833
License Number StateFL

VIII. Authorized Official

Name: KEITH MASSI
Title or Position: PRESIDENT
Credential: D.C.
Phone: 407-530-4734