Provider Demographics
NPI:1992992507
Name:SAFESPINE, LLC
Entity type:Organization
Organization Name:SAFESPINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:POOR
Authorized Official - Suffix:
Authorized Official - Credentials:MBR
Authorized Official - Phone:405-601-5979
Mailing Address - Street 1:8601 S WESTERN AVE
Mailing Address - Street 2:ROOM 108
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9200
Mailing Address - Country:US
Mailing Address - Phone:405-601-5979
Mailing Address - Fax:405-601-2826
Practice Address - Street 1:8601 S WESTERN AVE
Practice Address - Street 2:ROOM 108
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9200
Practice Address - Country:US
Practice Address - Phone:405-601-5979
Practice Address - Fax:405-601-2826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK6007650001Medicare NSC