Provider Demographics
NPI:1063260040
Name:SPINE CLINIC PHYSICIAN OF PUERTO RICO
Entity type:Organization
Organization Name:SPINE CLINIC PHYSICIAN OF PUERTO RICO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERTO
Authorized Official - Middle Name:JOSUE
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:939-225-7972
Mailing Address - Street 1:CENTRO INTERNACIONAL DE MERCADEO, TORRE 1
Mailing Address - Street 2:100 CARR. 165 SUITE 606
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00968-8048
Mailing Address - Country:US
Mailing Address - Phone:939-225-7972
Mailing Address - Fax:939-225-7974
Practice Address - Street 1:CENTRO INTERNACIONAL DE MERCADEO, TORRE 1
Practice Address - Street 2:100 CARR. 165 SUITE 606
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00968-8048
Practice Address - Country:US
Practice Address - Phone:939-225-7972
Practice Address - Fax:939-225-7974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-07
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1528705472Medicaid