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?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory