Provider Demographics
NPI:1306891718
Name:MICROSPINE SURGERY CENTER DEFUNIAK SPRINGS LLC
Entity type:Organization
Organization Name:MICROSPINE SURGERY CENTER DEFUNIAK SPRINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BARBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-892-6001
Mailing Address - Street 1:101 MICROSPINE WAY
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-6323
Mailing Address - Country:US
Mailing Address - Phone:850-892-6001
Mailing Address - Fax:850-892-4212
Practice Address - Street 1:101 MICROSPINE WAY
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-6323
Practice Address - Country:US
Practice Address - Phone:850-892-6001
Practice Address - Fax:850-892-4212
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICROSPINE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-23
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1155261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6B7OtherBCBS PROVIDER NUMBER
FLF1383Medicare ID - Type UnspecifiedPROVIDER NUMBER