Provider Demographics
NPI:1982044707
Name:SOUTHEAST SPINE CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHEAST SPINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ORTELIO
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-233-6811
Mailing Address - Street 1:7450 SKIDAWAY RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-6446
Mailing Address - Country:US
Mailing Address - Phone:912-233-6811
Mailing Address - Fax:912-544-0864
Practice Address - Street 1:7450 SKIDAWAY RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-6446
Practice Address - Country:US
Practice Address - Phone:912-233-6811
Practice Address - Fax:912-544-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051119261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical