=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811498900
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT SPINE & INJURY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2018
-----------------------------------------------------
Last Update Date | 04/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 W MARKET ST STE 301
-----------------------------------------------------
City | FAIRLAWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-818-2996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3200 W MARKET ST STE 301
-----------------------------------------------------
City | FAIRLAWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-818-2996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FRANK MONTALVO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-818-2996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------