Provider Demographics
NPI:1447798939
Name:CENTER FOR MINIMALLY INVASIVE SPINECARE, INC
Entity Type:Organization
Organization Name:CENTER FOR MINIMALLY INVASIVE SPINECARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MANGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-850-8408
Mailing Address - Street 1:50960 FOX TRL
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9039
Mailing Address - Country:US
Mailing Address - Phone:574-850-8408
Mailing Address - Fax:
Practice Address - Street 1:270 E DAY RD
Practice Address - Street 2:SUITE #200
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3444
Practice Address - Country:US
Practice Address - Phone:574-850-8408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065998A207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty