Provider Demographics
NPI:1932484367
Name:INNOVATIVE SPINE CARE, INC.
Entity Type:Organization
Organization Name:INNOVATIVE SPINE CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-360-6315
Mailing Address - Street 1:7000 BEACH PLZ APT 901
Mailing Address - Street 2:
Mailing Address - City:ST PETE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33706-3662
Mailing Address - Country:US
Mailing Address - Phone:727-360-6315
Mailing Address - Fax:408-228-8953
Practice Address - Street 1:1700 N MCMULLEN BOOTH RD
Practice Address - Street 2:SUITE A2-1
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-2130
Practice Address - Country:US
Practice Address - Phone:727-360-6315
Practice Address - Fax:408-228-8953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 105674208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty