Basic Information
| Provider Information | |||||||||
| NPI: | 1841208022 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPINE AND REHABILITATION CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3724 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE G-10 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787311646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123455925 | ||||||||
| FaxNumber: | 5123437113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3724 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE G-10 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787311646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123455925 | ||||||||
| FaxNumber: | 5123437113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 08/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | ATCHLEY | ||||||||
| AuthorizedOfficialFirstName: | JODI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5123455935 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2081P2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 111N00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.