Healthcare Provider Details

I. General information

NPI: 1558309450
Provider Name (Legal Business Name): LASER SPINE MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 N ROCKY POINT DR E STE 185
TAMPA FL
33607-5810
US

IV. Provider business mailing address

3001 N ROCKY POINT DR E STE 185
TAMPA FL
33607-5810
US

V. Phone/Fax

Practice location:
  • Phone: 813-289-9613
  • Fax:
Mailing address:
  • Phone: 813-289-9613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL PERRY
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 813-289-9613