Provider Demographics
NPI:1679913552
Name:SPINE SPORTS SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SPINE SPORTS SURGERY CENTER, LLC
Other - Org Name:SPINE AND SPORTS SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERMAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-378-6773
Mailing Address - Street 1:429 LLEWELLYN AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1948
Mailing Address - Country:US
Mailing Address - Phone:408-378-6773
Mailing Address - Fax:408-520-4295
Practice Address - Street 1:429 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1948
Practice Address - Country:US
Practice Address - Phone:408-378-6773
Practice Address - Fax:408-520-4295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-25
Last Update Date:2023-08-11
Deactivation Date:2023-07-17
Deactivation Code:
Reactivation Date:2023-08-11
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF1851OtherMEDICARE PTAN