Healthcare Provider Details

I. General information

NPI: 1588092795
Provider Name (Legal Business Name): SUMMIT SPINE AND SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2013
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 ASPEN DR SUITE 803-B
SANTA FE NM
87505-5459
US

IV. Provider business mailing address

1925 ASPEN DR SUITE 803-B
SANTA FE NM
87505-5459
US

V. Phone/Fax

Practice location:
  • Phone: 505-780-8617
  • Fax: 505-780-8617
Mailing address:
  • Phone: 505-780-8617
  • Fax: 505-780-8617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1723
License Number StateNM

VIII. Authorized Official

Name: DR. SCOTT E WILLIAMS
Title or Position: OWNER
Credential: D.C.
Phone: 505-780-8617