Provider Demographics
NPI:1336492487
Name:SPINE MINIVASIVE
Entity Type:Organization
Organization Name:SPINE MINIVASIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:C
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-959-7088
Mailing Address - Street 1:2646 S LOOP W
Mailing Address - Street 2:360
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2665
Mailing Address - Country:US
Mailing Address - Phone:888-959-7088
Mailing Address - Fax:
Practice Address - Street 1:2646 S LOOP W
Practice Address - Street 2:360
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2665
Practice Address - Country:US
Practice Address - Phone:888-959-7088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier