Provider Demographics
NPI:1255029799
Name:SPIRIT MEDICAL GROUP
Entity type:Organization
Organization Name:SPIRIT MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DZEBOLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-245-6475
Mailing Address - Street 1:1030 S GLENDALE AVE STE 506
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-2820
Mailing Address - Country:US
Mailing Address - Phone:818-245-6475
Mailing Address - Fax:818-245-6417
Practice Address - Street 1:1030 S GLENDALE AVE STE 506
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-2820
Practice Address - Country:US
Practice Address - Phone:818-245-6475
Practice Address - Fax:818-245-6417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center