Provider Demographics
NPI:1992113088
Name:EQUINOX SPINE PA
Entity type:Organization
Organization Name:EQUINOX SPINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:214-384-1642
Mailing Address - Street 1:7712 SAN JACINTO PL
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3257
Mailing Address - Country:US
Mailing Address - Phone:972-707-0005
Mailing Address - Fax:888-992-6199
Practice Address - Street 1:3160 NORTH TARRANT PARKWAY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177
Practice Address - Country:US
Practice Address - Phone:972-707-0005
Practice Address - Fax:888-992-6199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-01
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7365207XS0117X
TXK8470207XS0117X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX340015YYZKMedicare UPIN
TX340015YYZLMedicare UPIN