Provider Demographics
NPI:1417476912
Name:SPINE INFORMATICS AUSTIN, LLC
Entity Type:Organization
Organization Name:SPINE INFORMATICS AUSTIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DEVRIES
Authorized Official - Suffix:JR
Authorized Official - Credentials:INVESTOR
Authorized Official - Phone:512-913-1834
Mailing Address - Street 1:3202 SWEET AUTUMN CV
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-1524
Mailing Address - Country:US
Mailing Address - Phone:512-913-1834
Mailing Address - Fax:512-537-1537
Practice Address - Street 1:110 WILD BASIN RD STE 250
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-3352
Practice Address - Country:US
Practice Address - Phone:512-531-9912
Practice Address - Fax:512-537-1537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology