Provider Demographics
NPI:1225754294
Name:PONTE VEDRA SPINE CENTER LLC
Entity Type:Organization
Organization Name:PONTE VEDRA SPINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GION
Authorized Official - Middle Name:
Authorized Official - Last Name:MONN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:937-602-2095
Mailing Address - Street 1:220 PONTE VEDRA PARK DR STE 180
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 PONTE VEDRA PARK DR STE 180
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-6616
Practice Address - Country:US
Practice Address - Phone:937-602-2092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty