Provider Demographics
NPI:1932598760
Name:SPINE & SPORTS SURGICAL CENTER, LLC.
Entity Type:Organization
Organization Name:SPINE & SPORTS SURGICAL CENTER, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-598-1745
Mailing Address - Street 1:1120 W LA VETA AVE # 330
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4231
Mailing Address - Country:US
Mailing Address - Phone:714-598-1745
Mailing Address - Fax:714-941-9539
Practice Address - Street 1:1120 W LA VETA AVE
Practice Address - Street 2:300
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4231
Practice Address - Country:US
Practice Address - Phone:714-598-1745
Practice Address - Fax:714-941-9539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-16
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical