Basic Information
| Provider Information | |||||||||
| NPI: | 1154600070 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DISC SPORTS AND SPINE CENTER AT NEWPORT BEACH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13160 MINDANAO WAY | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | MARINA DEL REY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902926358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105740450 | ||||||||
| FaxNumber: | 3105740371 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 JAMBOREE RD | ||||||||
| Address2: | SUIUTE 1200 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926602939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499887888 | ||||||||
| FaxNumber: | 9495097907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2011 | ||||||||
| LastUpdateDate: | 08/09/2011 | ||||||||
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| AuthorizedOfficialLastName: | DALE | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3105740450 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.