Provider Demographics
NPI:1598233249
Name:MIDLANDS SPINE CENTER LLC
Entity Type:Organization
Organization Name:MIDLANDS SPINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:MUBARAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:803-791-3900
Mailing Address - Street 1:1525 SUNSET BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-5957
Mailing Address - Country:US
Mailing Address - Phone:803-791-3900
Mailing Address - Fax:803-791-7899
Practice Address - Street 1:5076 SUNSET BLVD STE C
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7050
Practice Address - Country:US
Practice Address - Phone:803-520-0084
Practice Address - Fax:803-520-7284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-10
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty