Healthcare Provider Details

I. General information

NPI: 1154040640
Provider Name (Legal Business Name): PSL ORTHO SPINE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 NW PEACOCK BLVD STE 204
PORT ST LUCIE FL
34986-2271
US

IV. Provider business mailing address

266 NW PEACOCK BLVD STE 204
PORT ST LUCIE FL
34986-2271
US

V. Phone/Fax

Practice location:
  • Phone: 772-262-0852
  • Fax: 772-245-4235
Mailing address:
  • Phone: 772-262-0852
  • Fax: 772-245-4235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURA C BEATTY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 772-262-0852