Provider Demographics
NPI:1528168333
Name:SAN DIEGO SPINE & SPORT, INC
Entity type:Organization
Organization Name:SAN DIEGO SPINE & SPORT, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-208-8526
Mailing Address - Street 1:3670 CONVOY STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3743
Mailing Address - Country:US
Mailing Address - Phone:888-208-8526
Mailing Address - Fax:858-751-0901
Practice Address - Street 1:1501 OCOTILLO DR
Practice Address - Street 2:SUITE B
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4217
Practice Address - Country:US
Practice Address - Phone:760-679-0210
Practice Address - Fax:760-679-0213
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN DIEGO SPINE & SPORT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-22
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1295798676OtherNPI
CA1750344131OtherNPI
CA1821051202OtherNPI
CA1295798676OtherNPI