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General NPI Number Information
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NPI Number | 1245649557
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Entity Type | Organization
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Legal Business Name | ISPINE (PRIMETIME REHABILITATION AND PERFORMANCE DIVISION)
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Dates
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Enumeration Date | 08/12/2014
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Last Update Date | 08/12/2014
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Provider Practice Location Address
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Address Line | 2710 N JOSEY LN SUITE 302
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City | CARROLLTON
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State | TX
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Zip | 75007-5400
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Country | US
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Telephone | 832-969-2784
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Fax |
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Provider Business Mailing Address
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Address Line | 2220 CANTON ST APT 211
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City | DALLAS
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State | TX
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Zip | 75201-5932
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Country | US
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Telephone | 832-969-2784
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. REGINALD JAMES NEWSOME
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Credential | MD
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Telephone | 832-969-2784
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | M8869
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License Number State | TX
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