Healthcare Provider Details

I. General information

NPI: 1538281373
Provider Name (Legal Business Name): SPINE CLINIC PTPP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3724 EXECUTIVE CENTER DR STE G10
AUSTIN TX
78731-1665
US

IV. Provider business mailing address

3724 EXECUTIVE CENTER DR STE G10
AUSTIN TX
78731-1665
US

V. Phone/Fax

Practice location:
  • Phone: 512-345-5925
  • Fax: 512-343-7113
Mailing address:
  • Phone: 512-345-5925
  • Fax: 512-343-7113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NICOLE DIXON
Title or Position: HUMAN RESOURCES
Credential:
Phone: 512-345-5925