Provider Demographics
NPI:1669756227
Name:PREMIER SPINE SPECIALISTS, LLC
Entity type:Organization
Organization Name:PREMIER SPINE SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-345-3933
Mailing Address - Street 1:10801 SW TRADITION SQ
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-1934
Mailing Address - Country:US
Mailing Address - Phone:772-345-3933
Mailing Address - Fax:772-345-3937
Practice Address - Street 1:10801 SW TRADITION SQ
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-1934
Practice Address - Country:US
Practice Address - Phone:772-345-3933
Practice Address - Fax:772-345-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1054832081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty