Provider Demographics
NPI:1043481450
Name:INLAND EMPIRE SPINAL DECOMPRESSION CENTERS
Entity Type:Organization
Organization Name:INLAND EMPIRE SPINAL DECOMPRESSION CENTERS
Other - Org Name:INLAND VALLEY SPINAL DECOMPRESSION CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:HUGO
Authorized Official - Last Name:FANTASIA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:909-986-1611
Mailing Address - Street 1:203 W G ST STE B
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3227
Mailing Address - Country:US
Mailing Address - Phone:909-986-1611
Mailing Address - Fax:909-467-5594
Practice Address - Street 1:203 W G ST
Practice Address - Street 2:STE B
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3227
Practice Address - Country:US
Practice Address - Phone:909-986-1611
Practice Address - Fax:909-467-5594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15464261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366626707OtherINDIVIDUAL NPI NUMBER