Provider Demographics
NPI:1992913040
Name:BRAIN AND SPINE WORK ASSESSMENT AND THERAPY CENTER
Entity type:Organization
Organization Name:BRAIN AND SPINE WORK ASSESSMENT AND THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-747-0400
Mailing Address - Street 1:2101 NORTHSIDE DR
Mailing Address - Street 2:SUITE 502
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3685
Mailing Address - Country:US
Mailing Address - Phone:850-913-7040
Mailing Address - Fax:850-913-0290
Practice Address - Street 1:2101 NORTHSIDE DR
Practice Address - Street 2:SUITE 502
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-3685
Practice Address - Country:US
Practice Address - Phone:850-913-7040
Practice Address - Fax:850-913-0290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT4387174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY924SOtherBCBS SUPER Y GROUP #