Provider Demographics
NPI:1689824203
Name:MDRS SPINE & SPORT, INC
Entity Type:Organization
Organization Name:MDRS SPINE & SPORT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-264-1417
Mailing Address - Street 1:3760 CONVOY ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3743
Mailing Address - Country:US
Mailing Address - Phone:888-208-8526
Mailing Address - Fax:858-751-0901
Practice Address - Street 1:41715 WINCHESTER RD
Practice Address - Street 2:SUITE 202
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-4808
Practice Address - Country:US
Practice Address - Phone:951-296-0788
Practice Address - Fax:951-296-3661
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MDRS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-19
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003934381OtherNPI
CA1447215397OtherNPI
CADA887YMedicare PIN
CAW15369Medicare PIN
CA1447215397OtherNPI