=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700080546
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAREDO SPINE MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6423 MCPHERSON RD STE 9
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-6179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-791-3733
-----------------------------------------------------
Fax | 956-791-3724
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6423 MCPHERSON RD STE 9
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-6179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-791-3733
-----------------------------------------------------
Fax | 956-791-3724
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LISA GARCIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-791-3733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------