Provider Demographics
NPI:1508095894
Name:INNOVATIVE SPINE SURGERY
Entity Type:Organization
Organization Name:INNOVATIVE SPINE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MORTEZA
Authorized Official - Middle Name:M
Authorized Official - Last Name:FARR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:831-713-8879
Mailing Address - Street 1:140 PELTON AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-6142
Mailing Address - Country:US
Mailing Address - Phone:831-713-8879
Mailing Address - Fax:
Practice Address - Street 1:1575 SOQUEL DR
Practice Address - Street 2:B
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1700
Practice Address - Country:US
Practice Address - Phone:831-464-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020A80782207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH07328Medicare UPIN