Provider Demographics
NPI:1942226758
Name:SPINE AND SPORTS MEDICINE INSTITUTE, INC.
Entity Type:Organization
Organization Name:SPINE AND SPORTS MEDICINE INSTITUTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:DRISCOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-686-5400
Mailing Address - Street 1:2600 STANWELL DRIVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4862
Mailing Address - Country:US
Mailing Address - Phone:925-686-5400
Mailing Address - Fax:
Practice Address - Street 1:2600 STANWELL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4862
Practice Address - Country:US
Practice Address - Phone:925-686-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2014-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ26603ZMedicare PIN