Provider Demographics
NPI:1407917370
Name:WESTERN SPINAL CENTER PLLC
Entity Type:Organization
Organization Name:WESTERN SPINAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:D
Authorized Official - Last Name:SIPE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:623-334-9689
Mailing Address - Street 1:8751 N 51ST AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-4945
Mailing Address - Country:US
Mailing Address - Phone:623-334-9689
Mailing Address - Fax:623-334-9687
Practice Address - Street 1:8751 N 51ST AVE
Practice Address - Street 2:SUITE 124
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302
Practice Address - Country:US
Practice Address - Phone:623-334-9689
Practice Address - Fax:623-334-9687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3483111N00000X
AZ7011225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0421610OtherBLUE CROSS BLUE SHIELD
0421610OtherBLUE CROSS BLUE SHIELD
AZ6129730001Medicare NSC