Provider Demographics
NPI:1417992264
Name:MOUNTAIN SPINE AND ACCIDENT CENTER LLC
Entity Type:Organization
Organization Name:MOUNTAIN SPINE AND ACCIDENT CENTER LLC
Other - Org Name:MOUNTAIN MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-575-2225
Mailing Address - Street 1:777 DELTONA BLVD
Mailing Address - Street 2:SUITE 21
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-7173
Mailing Address - Country:US
Mailing Address - Phone:386-575-2225
Mailing Address - Fax:386-575-1096
Practice Address - Street 1:777 DELTONA BLVD
Practice Address - Street 2:SUITE 21
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-7173
Practice Address - Country:US
Practice Address - Phone:386-575-2225
Practice Address - Fax:386-575-1096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 8010261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU91264Medicare UPIN
FL5701440001Medicare NSC