Healthcare Provider Details

I. General information

NPI: 1275041147
Provider Name (Legal Business Name): SPINE CIN OF WEST PALM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2018
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 PGA BLVD # 600A
PALM BEACH GARDENS FL
33410-6539
US

IV. Provider business mailing address

102 WOODMONT BLVD STE 350
NASHVILLE TN
37205-2216
US

V. Phone/Fax

Practice location:
  • Phone: 615-386-0064
  • Fax: 615-386-0067
Mailing address:
  • Phone: 615-386-0064
  • Fax: 615-386-0067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: EDWARD LELAND HUTTON EADIE
Title or Position: PE SPECIALIST
Credential:
Phone: 615-733-2064