Healthcare Provider Details

I. General information

NPI: 1811945025
Provider Name (Legal Business Name): NEUROSPINE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74B CENTENNIAL LOOP SUITE 100
EUGENE OR
97401-7918
US

IV. Provider business mailing address

74B CENTENNIAL LOOP STE 300
EUGENE OR
97401-7925
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-3791
  • Fax: 541-686-3795
Mailing address:
  • Phone: 541-686-3791
  • Fax: 541-686-3795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE LEISHMAN
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 541-686-3791