=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275231466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED JOINT AND SPINE INSTITUTE-ORLANDO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2023
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7974 LAKE UNDERHILL ROAD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-256-0933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7974 LAKE UNDERHILL RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32822-8229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-710-9899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MARKET PRESIDENT
-----------------------------------------------------
Name | MR. CHARLES TOMLINSON KLINE IV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-396-9391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------