Provider Demographics
NPI:1346714797
Name:ALLEGIANCE ORTHOPEDIC NEUROSURGERY AND SPINE INSTITUTE LLC
Entity Type:Organization
Organization Name:ALLEGIANCE ORTHOPEDIC NEUROSURGERY AND SPINE INSTITUTE LLC
Other - Org Name:BLACKSTONE MEDICAL GROUP LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:RICCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-306-5383
Mailing Address - Street 1:190 CONGRESS PARK DR STE 160
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-4707
Mailing Address - Country:US
Mailing Address - Phone:561-306-5383
Mailing Address - Fax:
Practice Address - Street 1:190 CONGRESS PARK DR STE 160
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-4707
Practice Address - Country:US
Practice Address - Phone:561-306-5383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-18
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center