Provider Demographics
NPI:1144865726
Name:SPINE & NERVE DIAGNOSTIC CENTER
Entity type:Organization
Organization Name:SPINE & NERVE DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:VINAY
Authorized Official - Middle Name:MOOLA
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-772-5325
Mailing Address - Street 1:1528 EUREKA RD STE 103
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3047
Mailing Address - Country:US
Mailing Address - Phone:916-772-5325
Mailing Address - Fax:
Practice Address - Street 1:4200 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-5902
Practice Address - Country:US
Practice Address - Phone:916-722-5325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPINE & NERVE DIAGNOSTIC CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty