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General NPI Number Information
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NPI Number | 1588234447
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Entity Type | Organization
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Legal Business Name | RESTORATIVE SPINE AND PAIN, INC.
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Dates
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Enumeration Date | 07/01/2021
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Last Update Date | 07/28/2021
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Provider Practice Location Address
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Address Line | 1050 LAS TABLAS RD STE 12
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City | TEMPLETON
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State | CA
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Zip | 93465-9480
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Country | US
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Telephone | 805-242-1156
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Fax |
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Provider Business Mailing Address
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Address Line | 1375 E GRAND AVE STE 103
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City | ARROYO GRANDE
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State | CA
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Zip | 93420-2421
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | MATTHEW HADILAKSONO
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Credential | DO
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Telephone | 310-500-7966
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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