Provider Demographics
NPI:1982088365
Name:CENTER FOR INTERVENTIONAL SPINE, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CENTER FOR INTERVENTIONAL SPINE, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GEARITY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-877-5419
Mailing Address - Street 1:311 PARK PLACE BLVD
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759
Mailing Address - Country:US
Mailing Address - Phone:727-877-5419
Mailing Address - Fax:727-877-5419
Practice Address - Street 1:1817 PROFESSIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:727-877-5419
Practice Address - Fax:727-877-5419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60900332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site