Provider Demographics
NPI:1275510141
Name:NEOSPINE PUYALLUP SPINE CENTER, LLC
Entity Type:Organization
Organization Name:NEOSPINE PUYALLUP SPINE CENTER, LLC
Other - Org Name:MICROSURGICAL SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:1519 3RD ST SE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3742
Mailing Address - Country:US
Mailing Address - Phone:253-841-0705
Mailing Address - Fax:253-841-4527
Practice Address - Street 1:1519 3RD ST SE
Practice Address - Street 2:SUITE 102
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3742
Practice Address - Country:US
Practice Address - Phone:253-841-0705
Practice Address - Fax:253-841-4527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-30
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
G8857246Medicare PIN
WA8857246Medicare ID - Type UnspecifiedMEDICARE B PROVIDER