Provider Demographics
NPI:1912560798
Name:JACKSONVILLE SPINE CENTER PA
Entity Type:Organization
Organization Name:JACKSONVILLE SPINE CENTER PA
Other - Org Name:JAX SPINE & PAIN CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-223-3321
Mailing Address - Street 1:5191 FIRST COAST TECH PKWY
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224
Mailing Address - Country:US
Mailing Address - Phone:904-223-3321
Mailing Address - Fax:904-223-2169
Practice Address - Street 1:2349 VILLAGE SQUARE PKWY STE 107
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4319
Practice Address - Country:US
Practice Address - Phone:904-223-3321
Practice Address - Fax:904-223-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-17
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty