Provider Demographics
NPI:1376839902
Name:CORAL DESERT SPINE SURGERY
Entity Type:Organization
Organization Name:CORAL DESERT SPINE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:435-656-8366
Mailing Address - Street 1:1490 E FOREMASTER DR STE 220
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4498
Mailing Address - Country:US
Mailing Address - Phone:435-656-8366
Mailing Address - Fax:435-656-8370
Practice Address - Street 1:1490 E FOREMASTER DR STE 220
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4498
Practice Address - Country:US
Practice Address - Phone:435-656-8366
Practice Address - Fax:435-656-8370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5064080-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty