Provider Demographics
NPI:1245562511
Name:SPINE CENTER OF SOUTH FLORIDA, LLC
Entity Type:Organization
Organization Name:SPINE CENTER OF SOUTH FLORIDA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:JENEANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WAKULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-546-9591
Mailing Address - Street 1:815 SE 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-7102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 SE 1ST AVE
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-7102
Practice Address - Country:US
Practice Address - Phone:772-546-9591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98523174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty