Provider Demographics
NPI:1033743968
Name:MOBILE SPINE SPECIALIST LLC
Entity Type:Organization
Organization Name:MOBILE SPINE SPECIALIST LLC
Other - Org Name:MOBILE SPINE SPECIALIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUM
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MPT, DIP MDT
Authorized Official - Phone:512-559-6551
Mailing Address - Street 1:601 QUAIL VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-8051
Mailing Address - Country:US
Mailing Address - Phone:512-559-6551
Mailing Address - Fax:512-591-0789
Practice Address - Street 1:601 QUAIL VALLEY DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-8051
Practice Address - Country:US
Practice Address - Phone:512-559-6551
Practice Address - Fax:512-591-0789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-01
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy