Provider Demographics
NPI:1881461713
Name:SPINE SPORTS SURGERY CENTER, LLC
Entity type:Organization
Organization Name:SPINE SPORTS SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERMAN
Authorized Official - Middle Name:NAM
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-364-1616
Mailing Address - Street 1:3803 S BASCOM AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-7317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3803 S BASCOM AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-7317
Practice Address - Country:US
Practice Address - Phone:408-378-6773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPINE SPORTS SURGERY CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical