Provider Demographics
NPI:1356864078
Name:VENTURA SPINE AND SPORT MEDICAL CENTER INC.
Entity Type:Organization
Organization Name:VENTURA SPINE AND SPORT MEDICAL CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-312-9082
Mailing Address - Street 1:4601 TELEPHONE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-5671
Mailing Address - Country:US
Mailing Address - Phone:805-642-4061
Mailing Address - Fax:805-642-7295
Practice Address - Street 1:4601 TELEPHONE RD.
Practice Address - Street 2:SUITE 110
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003
Practice Address - Country:US
Practice Address - Phone:805-642-4061
Practice Address - Fax:805-642-7295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27583261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service