Provider Demographics
NPI:1952770919
Name:SPINE & NERVE DIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:SPINE & NERVE DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VINAY
Authorized Official - Middle Name:MOOLA
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-772-5325
Mailing Address - Street 1:4200 DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-5902
Mailing Address - Country:US
Mailing Address - Phone:916-772-5325
Mailing Address - Fax:916-772-6333
Practice Address - Street 1:2234 LONGPORT CT STE 100
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7181
Practice Address - Country:US
Practice Address - Phone:916-478-0112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA143514OtherPTAN