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General NPI Number Information
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NPI Number | 1366780496
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Entity Type | Organization
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Legal Business Name | INTERVENTIONAL SPINE CENTER LLC
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Dates
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Enumeration Date | 01/24/2013
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Last Update Date | 01/24/2013
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Provider Practice Location Address
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Address Line | 150 SW 12TH AVE SUITE 101
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City | POMPANO BEACH
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State | FL
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Zip | 33069-3298
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Country | US
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Telephone | 561-543-8888
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Fax |
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Provider Business Mailing Address
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Address Line | 150 SW 12TH AVE SUITE 101
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City | POMPANO BEACH
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State | FL
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Zip | 33069-3298
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Country | US
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Telephone | 561-543-8888
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Fax |
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Authorized Official
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Title or Position | DOCTOR
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Name | RAHAT FADERANI
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Credential | DO
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Telephone | 561-543-8888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | OS10474
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License Number State | FL
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