Provider Demographics
NPI:1386855898
Name:PACIFIC SPINE CLINIC INC
Entity Type:Organization
Organization Name:PACIFIC SPINE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:MERCER
Authorized Official - Last Name:MCKINLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-489-2379
Mailing Address - Street 1:355 E GRAND AVE
Mailing Address - Street 2:SUITE 1-2
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3313
Mailing Address - Country:US
Mailing Address - Phone:760-489-2379
Mailing Address - Fax:760-489-8106
Practice Address - Street 1:355 E GRAND AVE
Practice Address - Street 2:SUITE 1-2
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3313
Practice Address - Country:US
Practice Address - Phone:760-489-2379
Practice Address - Fax:760-489-8106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30927207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW7780Medicare PIN