Provider Demographics
NPI:1417992835
Name:SPINAL DIAGNOSTICS & TREATMENT CENTER
Entity Type:Organization
Organization Name:SPINAL DIAGNOSTICS & TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:FIONNUALA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCELLIGOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-755-5096
Mailing Address - Street 1:901 CAMPUS DRIVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015
Mailing Address - Country:US
Mailing Address - Phone:650-755-0733
Mailing Address - Fax:650-755-3018
Practice Address - Street 1:901 CAMPUS DRIVE
Practice Address - Street 2:SUITE 310
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015
Practice Address - Country:US
Practice Address - Phone:650-755-0733
Practice Address - Fax:650-755-3018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ15378ZMedicare ID - Type Unspecified