US SPINE & SPORT KEARNY VILLA

Provider Demographics

• NPI: 1548253297
• Name: US SPINE & SPORT KEARNY VILLA
• Entity type: Organization
• Organization Name: US SPINE & SPORT KEARNY VILLA
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: CHIEF OPERATING OFFICER
• Authorized Official - First Name: JOE
• Authorized Official - Middle Name: L
• Authorized Official - Last Name: VERNA
• Authorized Official - Credentials: DC
• Authorized Official - Phone: 888-208-8526
• Mailing Address - Street 1: 3444 KEARNY VILLA RD
• Mailing Address - Street 2: SUITE 200
• Mailing Address - City: SAN DIEGO
• Mailing Address - State: CA
• Mailing Address - Zip Code: 92123-1959
• Mailing Address - Country: US
• Mailing Address - Phone: 888-208-8526
• Mailing Address - Fax: 858-751-0901
• Practice Address - Street 1: 3444 KEARNY VILLA RD
• Practice Address - Street 2: SUITE 205
• Practice Address - City: SAN DIEGO
• Practice Address - State: CA
• Practice Address - Zip Code: 92123-1959
• Practice Address - Country: US
• Practice Address - Phone: 858-573-9368
• Practice Address - Fax: 858-874-0582
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: MDRS, INC
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2005-08-29
• Last Update Date: 2010-12-14

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	225100000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist		Group - Multi-Specialty
No	224Z00000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Occupational Therapy Assistant		Group - Multi-Specialty
No	225000000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Orthotic Fitter		Group - Multi-Specialty
No	2251E1200X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist	Ergonomics	Group - Multi-Specialty
No	2251E1300X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist	Electrophysiology, Clinical	Group - Multi-Specialty
No	2251H1200X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist	Hand	Group - Multi-Specialty
No	2251S0007X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist	Sports	Group - Multi-Specialty
No	2251X0800X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist	Orthopedic	Group - Multi-Specialty
No	225200000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapy Assistant		Group - Multi-Specialty
No	225X00000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Occupational Therapist		Group - Multi-Specialty
No	225XH1200X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Occupational Therapist	Hand	Group - Multi-Specialty
No	111NS0005X	Chiropractic Providers	Chiropractor	Sports Physician	Group - Multi-Specialty
No	111NX0100X	Chiropractic Providers	Chiropractor	Occupational Health	Group - Multi-Specialty
No	111NX0800X	Chiropractic Providers	Chiropractor	Orthopedic	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
CA	WC20677I	Medicare ID - Type Unspecified	V MOONEY
CA	ZZZ19066Z	Medicare PIN
CA	W14848	Medicare ID - Type Unspecified	GROUP ID
CA	WPT25572B	Medicare ID - Type Unspecified	A VIEHMANN
CA	WPT28041B	Medicare ID - Type Unspecified	D SAUNDERS