Provider Demographics
NPI:1881186336
Name:PACIFIC SPORTS AND INTERVENTIONAL SPINE, LLC
Entity Type:Organization
Organization Name:PACIFIC SPORTS AND INTERVENTIONAL SPINE, LLC
Other - Org Name:PACIFIC SPORTS AND SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:REA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-743-9003
Mailing Address - Street 1:217 DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-5429
Mailing Address - Country:US
Mailing Address - Phone:541-743-9003
Mailing Address - Fax:541-284-0520
Practice Address - Street 1:217 DIVISION AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-5429
Practice Address - Country:US
Practice Address - Phone:541-686-3791
Practice Address - Fax:541-686-3795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27887208VP0014X
ORMD28629208VP0014X
ORPA00800363A00000X
ORPA00420363A00000X
ORPA152998363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500632183Medicaid
OR244117Medicaid
OR500604467Medicaid
OR500608609Medicaid
OR500624453Medicaid