=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497806442
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINAL HEALTH ASSOCIATES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 N NEVADA AVE SUITE A
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88201-1729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-623-2225
-----------------------------------------------------
Fax | 505-623-1170
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 N NEVADA AVE SUITE A
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88201-1729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-623-2225
-----------------------------------------------------
Fax | 505-623-1170
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BARRY A MATHISON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 505-623-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1438
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------