=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992113088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EQUINOX SPINE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2014
-----------------------------------------------------
Last Update Date | 08/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3160 NORTH TARRANT PARKWAY
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-707-0005
-----------------------------------------------------
Fax | 888-992-6199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7712 SAN JACINTO PL
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75024-3257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-707-0005
-----------------------------------------------------
Fax | 888-992-6199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARK VALENTE
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 214-384-1642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | K8470
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | N7365
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------