Provider Demographics
NPI:1356462915
Name:JOINT & SPINE CENTER PA
Entity Type:Organization
Organization Name:JOINT & SPINE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:PRUSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:936-295-1777
Mailing Address - Street 1:100 MEDICAL CENTER PARKWAY
Mailing Address - Street 2:SUITE #100
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340
Mailing Address - Country:US
Mailing Address - Phone:936-295-1777
Mailing Address - Fax:936-295-3680
Practice Address - Street 1:100 MEDICAL CENTER PARKWAY
Practice Address - Street 2:SUITE #100
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340
Practice Address - Country:US
Practice Address - Phone:936-295-1777
Practice Address - Fax:936-295-3680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5291111N00000X, 111NR0400X
TX1036200111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00L17LOtherBCBS I.D. NUMBER
TX00L17LOtherBCBS I.D. NUMBER