Provider Demographics
NPI:1568844124
Name:SPINEZONE MEDIICAL FITNESS
Entity Type:Organization
Organization Name:SPINEZONE MEDIICAL FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-316-7979
Mailing Address - Street 1:2535 CAMINO DEL RIO SOUTH, SUITE 150
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108
Mailing Address - Country:US
Mailing Address - Phone:619-574-8770
Mailing Address - Fax:866-813-1235
Practice Address - Street 1:2301 S MELROSE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-8788
Practice Address - Country:US
Practice Address - Phone:844-316-7979
Practice Address - Fax:866-813-1235
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPINEZONE MEDICAL FITNESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-19
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74016225100000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB219850Medicare PIN