Provider Demographics
NPI:1083128250
Name:INNOVATIVE PAIN & SPINE SPECIALISTS
Entity Type:Organization
Organization Name:INNOVATIVE PAIN & SPINE SPECIALISTS
Other - Org Name:PHARMA INNOVATIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:DORI
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-413-5010
Mailing Address - Street 1:7121 STEPHANIE LN STE 104
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7121 STEPHANIE LN STE 104
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5359
Practice Address - Country:US
Practice Address - Phone:402-413-5010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INNOVATIVE PAIN & SPINE SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy