Basic Information
| Provider Information | |||||||||
| NPI: | 1689824203 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MDRS SPINE & SPORT, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3760 CONVOY ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882088526 | ||||||||
| FaxNumber: | 8587510901 | ||||||||
| Practice Location | |||||||||
| Address1: | 41715 WINCHESTER RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925904808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512960788 | ||||||||
| FaxNumber: | 9512963661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2008 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | COLLADO | ||||||||
| AuthorizedOfficialFirstName: | ANGEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8582641417 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MDRS, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.