Provider Demographics
NPI:1114473972
Name:BURBANK SPINE AND PAIN SURGERY CENTER A PROFESSIONAL MEDICAL CORP
Entity Type:Organization
Organization Name:BURBANK SPINE AND PAIN SURGERY CENTER A PROFESSIONAL MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:AJAKWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-325-2088
Mailing Address - Street 1:2211 W MAGNOLIA BLVD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-1753
Mailing Address - Country:US
Mailing Address - Phone:818-325-2088
Mailing Address - Fax:818-563-6201
Practice Address - Street 1:2211 W MAGNOLIA BLVD
Practice Address - Street 2:SUITE 270
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1753
Practice Address - Country:US
Practice Address - Phone:818-325-2088
Practice Address - Fax:818-563-6201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical