Provider Demographics
NPI:1962088013
Name:ALPHA SPINE AND PAIN CLINIC PLLC
Entity type:Organization
Organization Name:ALPHA SPINE AND PAIN CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:PRAVEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMBALAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-753-6705
Mailing Address - Street 1:PO BOX 827
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98009-0827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3202 COLBY AVE STE B
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4324
Practice Address - Country:US
Practice Address - Phone:425-753-6705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-19
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty