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General NPI Number Information
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NPI Number | 1992913040
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Entity Type | Organization
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Legal Business Name | BRAIN AND SPINE WORK ASSESSMENT AND THERAPY CENTER
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2101 NORTHSIDE DR SUITE 502
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City | PANAMA CITY
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State | FL
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Zip | 32405-3685
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Country | US
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Telephone | 850-913-7040
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Fax | 850-913-0290
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Provider Business Mailing Address
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Address Line | 2101 NORTHSIDE DR SUITE 502
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City | PANAMA CITY
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State | FL
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Zip | 32405-3685
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Country | US
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Telephone | 850-913-7040
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Fax | 850-913-0290
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Authorized Official
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Title or Position | CEO
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Name | MR. RON SAMUELIAN
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Credential |
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Telephone | 850-747-0400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | PT4387
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License Number State | FL
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