Provider Demographics
NPI: | 1952394603 |
---|---|
Name: | MDRS SPINE & SPORT, INC |
Entity Type: | Organization |
Organization Name: | MDRS SPINE & SPORT, INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CREDENTIALING OFFICER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ANGEL |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | COLLADO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 858-264-1417 |
Mailing Address - Street 1: | 3760 CONVOY ST |
Mailing Address - Street 2: | SUITE 101 |
Mailing Address - City: | SAN DIEGO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92111-3743 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 888-208-8526 |
Mailing Address - Fax: | 858-751-0901 |
Practice Address - Street 1: | 3760 CONVOY STREET |
Practice Address - Street 2: | SUITE 100 |
Practice Address - City: | SAN DIEGO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92111-3743 |
Practice Address - Country: | US |
Practice Address - Phone: | 858-573-9368 |
Practice Address - Fax: | 858-874-0582 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-08-29 |
Last Update Date: | 2019-06-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Single Specialty | |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Single Specialty | |
No | 2251E1300X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Electrophysiology, Clinical | Group - Multi-Specialty |
No | 2251H1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand | Group - Multi-Specialty |
No | 2251S0007X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | Group - Multi-Specialty |
No | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | Group - Multi-Specialty |
No | 225200000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | Group - Multi-Specialty | |
No | 225800000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Recreation Therapist | Group - Multi-Specialty | |
No | 225XH1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | Group - Multi-Specialty |
No | 226300000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Kinesiotherapist | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 1073699674 | Other | NPI |
CA | 1396059713 | Other | NPI |
CA | DU462Z | Medicare PIN | |
CA | WPT29262B | Medicare PIN | |
CA | 1932419876 | Other | NPI |
CA | 1750344131 | Other | NPI |
CA | 1326361247 | Other | NPI |
CA | 1598843443 | Other | NPI |
CA | 1336103878 | Other | NPI |
CA | 1003879057 | Other | NPI |
CA | 1972810042 | Other | NPI |
CA | DH525Z | Medicare PIN | |
CA | WPT28039C | Medicare PIN | |
CA | 1558676825 | Other | NPI |
CA | 1962725879 | Other | NPI |
CA | DK315Z | Medicare PIN | |
CA | WPT33811A | Medicare PIN | |
CA | WPT34244A | Medicare PIN | |
CA | 1578526950 | Other | NPI |
CA | 1841253721 | Other | NPI |
CA | WOT243B | Medicare ID - Type Unspecified | A LUDWIG |
CA | W15369 | Medicare ID - Type Unspecified | GROUP ID |
CA | DA887Y | Medicare PIN | |
CA | DP384Z | Medicare PIN | |
CA | WPT25572A | Medicare PIN | |
CA | WPT32643A | Medicare PIN | |
CA | 1003934381 | Other | NPI |
CA | 1932309200 | Other | NPI |
CA | 1952446650 | Other | NPI |
CA | 1447215397 | Other | NPI |
CA | DG892Z | Medicare PIN | |
CA | DR273Z | Medicare PIN | |
CA | WPT33505A | Medicare PIN | |
CA | 1013221464 | Other | NPI |
CA | 1194727305 | Other | NPI |
CA | 1558324509 | Other | NPI |
CA | WC20677I | Medicare ID - Type Unspecified | V MOONEY |
CA | CZ250Z | Medicare PIN | |
CA | WPT25572 | Medicare PIN |