Provider Demographics
NPI:1619649258
Name:SUN VALLEY SPINE AND ORTHOPEDICS, PLLC
Entity Type:Organization
Organization Name:SUN VALLEY SPINE AND ORTHOPEDICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRO
Authorized Official - Prefix:
Authorized Official - First Name:SETH
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKNOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-459-9754
Mailing Address - Street 1:4400 STATE HIGHWAY 121 STE 405
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-4561
Mailing Address - Country:US
Mailing Address - Phone:469-459-9754
Mailing Address - Fax:
Practice Address - Street 1:1440 E MISSOURI AVE STE C102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2459
Practice Address - Country:US
Practice Address - Phone:480-877-1497
Practice Address - Fax:480-582-0366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-01
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty