=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669139259
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAIN AND SPINE SPECIALISTS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2021
-----------------------------------------------------
Last Update Date | 11/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1859 CHINAR TREE DR
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91784-2524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-920-1688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1859 CHINAR TREE DR
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91784-2524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-920-1688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WILLIAM HAMMESFAHR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 307-920-1688
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------