Provider Demographics
NPI: | 1801394440 |
---|---|
Name: | NEUSPINE THERAPY LLC |
Entity Type: | Organization |
Organization Name: | NEUSPINE THERAPY LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ARMEN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | DEUKMEDJIAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 813-333-1186 |
Mailing Address - Street 1: | 2653 BRUCE B DOWNS BLVD STE 108-168 |
Mailing Address - Street 2: | |
Mailing Address - City: | WESLEY CHAPEL |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33544-9206 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 813-997-2099 |
Mailing Address - Fax: | 813-280-6193 |
Practice Address - Street 1: | 12880 US 301 |
Practice Address - Street 2: | |
Practice Address - City: | DADE CITY |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33525-5801 |
Practice Address - Country: | US |
Practice Address - Phone: | 813-388-2935 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | NEUSPINE ANCILLARY LLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2018-01-29 |
Last Update Date: | 2019-10-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208VP0014X | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | Group - Multi-Specialty |