=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457190456
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ORTHO SPINE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2024
-----------------------------------------------------
Last Update Date | 05/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13112 HWY 110 S
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75707-6350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-521-0824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4020 N MACARTHUR BLVD
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75038-6419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-874-0926
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. VORANART K SUNAKAPADEE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 903-597-8007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------