Provider Demographics
NPI:1841592771
Name:SPINE SPA
Entity Type:Organization
Organization Name:SPINE SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:FAIRCHILD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:302-731-0869
Mailing Address - Street 1:101 BERWYCK CT
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-2078
Mailing Address - Country:US
Mailing Address - Phone:302-731-0869
Mailing Address - Fax:302-292-0669
Practice Address - Street 1:300 CHRISTIANA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:CHRISTIANA
Practice Address - State:DE
Practice Address - Zip Code:19702-1653
Practice Address - Country:US
Practice Address - Phone:302-731-0869
Practice Address - Fax:302-292-0669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEF1-0000788261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty