Provider Demographics
NPI:1083175483
Name:LAGS SPINE AND SPORTSCARE MEDICAL CENTERS, INC.
Entity Type:Organization
Organization Name:LAGS SPINE AND SPORTSCARE MEDICAL CENTERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:HALLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-432-1451
Mailing Address - Street 1:218 N I ST
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-0909
Mailing Address - Country:US
Mailing Address - Phone:805-736-7886
Mailing Address - Fax:
Practice Address - Street 1:777 S HAM LN STE G
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3593
Practice Address - Country:US
Practice Address - Phone:805-736-7886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty