Provider Demographics
NPI: | 1780819755 |
---|---|
Name: | SPINE SPORTS AND PAIN MEDICINE, PC |
Entity Type: | Organization |
Organization Name: | SPINE SPORTS AND PAIN MEDICINE, PC |
Other - Org Name: | PHYSICIANS RESOURCE LABS |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | MATTHEW |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | CAVACINI |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 260-969-6200 |
Mailing Address - Street 1: | PO BOX 8857 |
Mailing Address - Street 2: | |
Mailing Address - City: | FORT WAYNE |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46898-8857 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 260-969-6200 |
Mailing Address - Fax: | 260-969-6201 |
Practice Address - Street 1: | 7900 W JEFFERSON BLVD |
Practice Address - Street 2: | |
Practice Address - City: | FORT WAYNE |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46804-4128 |
Practice Address - Country: | US |
Practice Address - Phone: | 260-969-6200 |
Practice Address - Fax: | 260-969-6201 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | SPINE SPORTS AND PAIN MEDICINE |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2009-05-20 |
Last Update Date: | 2009-05-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 291U00000X | Laboratories | Clinical Medical Laboratory |