Provider Demographics
NPI:1245649557
Name:ISPINE (PRIMETIME REHABILITATION AND PERFORMANCE DIVISION)
Entity type:Organization
Organization Name:ISPINE (PRIMETIME REHABILITATION AND PERFORMANCE DIVISION)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-969-2784
Mailing Address - Street 1:2220 CANTON ST APT 211
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-5932
Mailing Address - Country:US
Mailing Address - Phone:832-969-2784
Mailing Address - Fax:
Practice Address - Street 1:2710 N JOSEY LN
Practice Address - Street 2:SUITE 302
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-5400
Practice Address - Country:US
Practice Address - Phone:832-969-2784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ISPINE SPORTS MEDICINE AND PAIN MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM88692081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty