=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093697641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J&P SPINE CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2025
-----------------------------------------------------
Last Update Date | 07/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1334 W HERNDON AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93711-0431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-538-3145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6079 N FRESNO ST STE 101
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93710-5276
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-538-3145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | JUSTICE OTCHERE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 682-433-9287
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------