Provider Demographics
NPI:1538218672
Name:SPINE INSTITUTE INC., A MEDICAL CORPORATION
Entity type:Organization
Organization Name:SPINE INSTITUTE INC., A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:CASC
Authorized Official - Phone:818-993-2542
Mailing Address - Street 1:4849 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 217
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2128
Mailing Address - Country:US
Mailing Address - Phone:818-990-4100
Mailing Address - Fax:818-990-4199
Practice Address - Street 1:4849 VAN NUYS BLVD
Practice Address - Street 2:SUITE 217
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2128
Practice Address - Country:US
Practice Address - Phone:818-990-4100
Practice Address - Fax:818-990-4199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68053207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty