Provider Demographics
NPI:1548467640
Name:THE SPINE WORX LLC
Entity type:Organization
Organization Name:THE SPINE WORX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PUCKA
Authorized Official - Suffix:
Authorized Official - Credentials:DC, LAC
Authorized Official - Phone:765-446-0000
Mailing Address - Street 1:983 S CREASY LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4800
Mailing Address - Country:US
Mailing Address - Phone:765-446-0000
Mailing Address - Fax:317-245-2153
Practice Address - Street 1:983 S CREASY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4800
Practice Address - Country:US
Practice Address - Phone:765-446-0000
Practice Address - Fax:317-245-2153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001350261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INF14099Medicare UPIN
INU25354Medicare PIN