Provider Demographics
NPI:1477106771
Name:SPINE CENTER OF SOUTHEAST GEORGIA LLC
Entity Type:Organization
Organization Name:SPINE CENTER OF SOUTHEAST GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BOVINET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-262-6552
Mailing Address - Street 1:52A LINDSEY LANE
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6855
Mailing Address - Country:US
Mailing Address - Phone:912-262-6552
Mailing Address - Fax:912-262-0112
Practice Address - Street 1:52A LINDSEY LANE
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6855
Practice Address - Country:US
Practice Address - Phone:912-262-6552
Practice Address - Fax:912-262-0112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-17
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty