Basic Information
| Provider Information | |||||||||
| NPI: | 1861411902 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPINE RECONSTRUCTION PARTNERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 S SAN VICENTE BLVD | ||||||||
| Address2: | SUITE #800 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900484165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104239900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 444 S SAN VICENTE BLVD | ||||||||
| Address2: | SUITE #800 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900484165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104239900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | PATRICK | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3104239900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | TAX ID NUMBER | 01 | CA | OTHER |