Provider Demographics
NPI:1982613782
Name:HEALTHSTAR SPINAL CENTER INC
Entity type:Organization
Organization Name:HEALTHSTAR SPINAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JIMA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS,RVT,RDCS
Authorized Official - Phone:772-465-1500
Mailing Address - Street 1:1611 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-6816
Mailing Address - Country:US
Mailing Address - Phone:772-465-1500
Mailing Address - Fax:772-465-0050
Practice Address - Street 1:2401 FRIST BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4839
Practice Address - Country:US
Practice Address - Phone:772-465-1500
Practice Address - Fax:772-465-0050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCCR3622261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7662Medicare ID - Type Unspecified