Healthcare Provider Details

I. General information

NPI: 1407335979
Provider Name (Legal Business Name): LAGS SPINE AND SPORTSCARE MEDICAL CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17175 SW TUALATIN VALLEY HWY
BEAVERTON OR
97003-4584
US

IV. Provider business mailing address

218 NORTH I STREET
LOMPOC CA
93436
US

V. Phone/Fax

Practice location:
  • Phone: 805-736-7886
  • Fax: 805-736-7867
Mailing address:
  • Phone: 805-736-7886
  • Fax: 805-736-7867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: SARA SHOWERS
Title or Position: MEDICAL BILLING SPECIALIST LEAD
Credential:
Phone: 805-928-7361