Provider Demographics
NPI:1336567627
Name:NEUROSPINE LLC
Entity Type:Organization
Organization Name:NEUROSPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:C
Authorized Official - Last Name:CARSWELL STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-364-9010
Mailing Address - Street 1:8230 BOONE BLVD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2621
Mailing Address - Country:US
Mailing Address - Phone:703-889-8959
Mailing Address - Fax:703-370-0706
Practice Address - Street 1:8230 BOONE BLVD
Practice Address - Street 2:SUITE 360
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2621
Practice Address - Country:US
Practice Address - Phone:703-889-8959
Practice Address - Fax:703-370-0706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101254853174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H35452Medicare UPIN