Healthcare Provider Details

I. General information

NPI: 1306756275
Provider Name (Legal Business Name): PRIME ORTHO & SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 HAMBURG TPKE STE 209
WAYNE NJ
07470-2166
US

IV. Provider business mailing address

2001 W SAMPLE RD STE 318
DEERFIELD BEACH FL
33064-1342
US

V. Phone/Fax

Practice location:
  • Phone: 954-751-4490
  • Fax:
Mailing address:
  • Phone: 954-751-4490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SHATINA CANNON
Title or Position: ADMINISTRATOR
Credential:
Phone: 954-751-4490