Provider Demographics
NPI:1740311679
Name:PACIFIC SPINE SPECIALISTS, LLC
Entity type:Organization
Organization Name:PACIFIC SPINE SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MS
Authorized Official - First Name:FAYE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KAISER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-783-0201
Mailing Address - Street 1:19260 SW 65TH AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-5705
Mailing Address - Country:US
Mailing Address - Phone:503-885-9391
Mailing Address - Fax:503-783-0909
Practice Address - Street 1:19260 SW 65TH AVE STE 270
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-5705
Practice Address - Country:US
Practice Address - Phone:503-885-9391
Practice Address - Fax:503-783-0909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15842174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241875Medicaid
ORA49072Medicare UPIN
OR241875Medicaid
ORR113017Medicare ID - Type UnspecifiedPRACTICE ID NUMBER