Provider Demographics
NPI:1326617176
Name:ED SPINE CLINIC LLC
Entity Type:Organization
Organization Name:ED SPINE CLINIC LLC
Other - Org Name:ED SPINE CLINIC LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERBETT
Authorized Official - Middle Name:SALVA
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:787-517-4828
Mailing Address - Street 1:139 CALLE R
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00603-1409
Mailing Address - Country:US
Mailing Address - Phone:787-517-4828
Mailing Address - Fax:
Practice Address - Street 1:120 CALLE BELT
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-1106
Practice Address - Country:US
Practice Address - Phone:787-517-4828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-24
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty