Provider Demographics
NPI:1447746219
Name:SPINEWELL DISC & JOINT CENTERS LLC
Entity Type:Organization
Organization Name:SPINEWELL DISC & JOINT CENTERS LLC
Other - Org Name:DISC CENTERS OF AMERICA - PONTE VEDRA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:L
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-644-3472
Mailing Address - Street 1:1400 MARSH LANDING PKWY STE 107
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2492
Mailing Address - Country:US
Mailing Address - Phone:904-644-3472
Mailing Address - Fax:
Practice Address - Street 1:1400 MARSH LANDING PKWY STE 107
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-2492
Practice Address - Country:US
Practice Address - Phone:904-644-3472
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-05
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012784111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty