Provider Demographics
NPI:1861043929
Name:SPINE CENTER OF FL LLC
Entity Type:Organization
Organization Name:SPINE CENTER OF FL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:WISOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-927-5772
Mailing Address - Street 1:11921 ROCKVILLE PIKE STE 505
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2758
Mailing Address - Country:US
Mailing Address - Phone:301-945-5111
Mailing Address - Fax:
Practice Address - Street 1:9400 BONITA BEACH RD SE STE 101
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4520
Practice Address - Country:US
Practice Address - Phone:239-333-1177
Practice Address - Fax:239-333-1169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty