Provider Demographics
NPI:1558911818
Name:SPACE COAST SPINE LLC.
Entity Type:Organization
Organization Name:SPACE COAST SPINE LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMBURSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-281-7900
Mailing Address - Street 1:1402 DUNLAWTON AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-2917
Mailing Address - Country:US
Mailing Address - Phone:386-227-6688
Mailing Address - Fax:
Practice Address - Street 1:1402 DUNLAWTON AVE STE 2B
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-2917
Practice Address - Country:US
Practice Address - Phone:386-227-6688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-18
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty