MEDICARE: MINIMALLY INVASIVE SPINE CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1215296967
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINIMALLY INVASIVE SPINE CENTER LLC

Provider Business Mailing Address
First Line	:	2401 S SEACREST BLVD
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33435-6514
Country	:	US
Telephone Number	:	561-733-8133
Fax Number	:	561-733-6670

Provider Business Practice Location Address
First Line	:	2314 S SEACREST BLVD
Second Line	:	SUITE 102
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33435-6788
Country	:	US
Telephone Number	:	561-733-8133
Fax Number	:	561-733-6670

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. SALAM I DAGHER
Credential	:
Telephone Number	:	561-733-8133

Provider Enumeration Date	:	05/15/2012
Last Update Date	:	05/15/2012

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