Provider Demographics
NPI:1831440981
Name:VENTURA ORTHOPEDIC SPINE, INC
Entity type:Organization
Organization Name:VENTURA ORTHOPEDIC SPINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:805-648-3902
Mailing Address - Street 1:168 N BRENT ST
Mailing Address - Street 2:SUITE 505
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2840
Mailing Address - Country:US
Mailing Address - Phone:805-648-3902
Mailing Address - Fax:805-648-4014
Practice Address - Street 1:168 N BRENT ST
Practice Address - Street 2:SUITE 505
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2840
Practice Address - Country:US
Practice Address - Phone:805-648-3902
Practice Address - Fax:805-648-4014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-28
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4466207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GT357AMedicare PIN