Healthcare Provider Details

I. General information

NPI: 1730312786
Provider Name (Legal Business Name): LASER SPINE INSTITUTE OF PENNSYLVANIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2009
Last Update Date: 08/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 E SWEDESFORD RD SUITE 100
WAYNE PA
19087-1606
US

IV. Provider business mailing address

656 E SWEDESFORD RD SUITE 100
WAYNE PA
19087-1606
US

V. Phone/Fax

Practice location:
  • Phone: 813-289-9613
  • Fax: 813-418-4112
Mailing address:
  • Phone: 813-289-9613
  • Fax: 813-418-4112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. CRAIG S NIEBUR
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 813-289-9613