=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285963389
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINE PHYSICIANS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2009
-----------------------------------------------------
Last Update Date | 12/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20940 N TATUM BLVD SUITE 350
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85050-4265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-503-3344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8912 E PINNACLE PEAK RD SUITE F9-644
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85255-3659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-503-3344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | RANDALL C PRUITT
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 480-503-3344
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------