Provider Demographics
NPI:1760718175
Name:DESOTO SPINE CENTER, PLLC
Entity Type:Organization
Organization Name:DESOTO SPINE CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:E
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:469-567-8242
Mailing Address - Street 1:1233 E PLEASANT RUN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-4200
Mailing Address - Country:US
Mailing Address - Phone:469-567-8242
Mailing Address - Fax:469-567-8290
Practice Address - Street 1:1233 E PLEASANT RUN RD
Practice Address - Street 2:SUITE B
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4200
Practice Address - Country:US
Practice Address - Phone:469-567-8242
Practice Address - Fax:469-567-8290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5472111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84NVOtherBLUE CROSS/BLUE SHIELD