Provider Demographics
NPI:1992736557
Name:SPINE CARE CENTER, LLC
Entity type:Organization
Organization Name:SPINE CARE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MATSUMURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-685-7246
Mailing Address - Street 1:6750 S HIGHLAND DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121
Mailing Address - Country:US
Mailing Address - Phone:801-685-7246
Mailing Address - Fax:801-747-5487
Practice Address - Street 1:6750 S HIGHLAND DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121
Practice Address - Country:US
Practice Address - Phone:801-685-7246
Practice Address - Fax:801-747-5487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000059455Medicare PIN