Basic Information
Provider Information | |||||||||
NPI: | 1790913705 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPINE CONNECT LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2411 FOUNTAIN VIEW DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770574851 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2817687630 | ||||||||
FaxNumber: | 2817686766 | ||||||||
Practice Location | |||||||||
Address1: | 2411 FOUNTAIN VIEW DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770574851 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2817687630 | ||||||||
FaxNumber: | 2817686766 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2009 | ||||||||
LastUpdateDate: | 06/29/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRETZ | ||||||||
AuthorizedOfficialFirstName: | GEORGE | ||||||||
AuthorizedOfficialMiddleName: | EDWARD | ||||||||
AuthorizedOfficialTitleorPosition: | GENERAL PARTNER | ||||||||
AuthorizedOfficialTelephone: | 2817686730 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
No ID Information.