Provider Demographics
NPI:1952320095
Name:SPINE CENTER OF LOS ANGELES INC.
Entity Type:Organization
Organization Name:SPINE CENTER OF LOS ANGELES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-322-4278
Mailing Address - Street 1:444 S SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4165
Mailing Address - Country:US
Mailing Address - Phone:310-423-9900
Mailing Address - Fax:
Practice Address - Street 1:122 SHELDON ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3915
Practice Address - Country:US
Practice Address - Phone:310-322-4278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61860207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15231Medicare ID - Type Unspecified