=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982088365
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR INTERVENTIONAL SPINE, A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2015
-----------------------------------------------------
Last Update Date | 07/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1817 PROFESSIONAL DRIVE
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-877-5419
-----------------------------------------------------
Fax | 727-877-5419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 PARK PLACE BLVD 5TH FLOOR
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-877-5419
-----------------------------------------------------
Fax | 727-877-5419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | LESLEY GEARITY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-877-5419
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | A60900
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------