=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841592771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINE SPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2010
-----------------------------------------------------
Last Update Date | 11/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 CHRISTIANA MEDICAL CTR
-----------------------------------------------------
City | CHRISTIANA
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19702-1653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-731-0869
-----------------------------------------------------
Fax | 302-292-0669
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 BERWYCK CT
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19702-2078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-731-0869
-----------------------------------------------------
Fax | 302-292-0669
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BRENDA A FAIRCHILD
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 302-731-0869
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | F1-0000788
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------