Healthcare Provider Details

I. General information

NPI: 1962764142
Provider Name (Legal Business Name): MYRTLE BEACH SPINE CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LEGENDS RD SUITE A
MYRTLE BEACH SC
29579-7076
US

IV. Provider business mailing address

100 LEGENDS RD STE A
MYRTLE BEACH SC
29579-7076
US

V. Phone/Fax

Practice location:
  • Phone: 843-236-9090
  • Fax: 843-236-9099
Mailing address:
  • Phone: 919-394-3225
  • Fax: 843-236-9099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL P GAMBACORTA
Title or Position: OWNER
Credential: DC, FNP-BC
Phone: 843-236-9090