Provider Demographics
NPI:1174250070
Name:REDEFINE YOUR SPINE LLC
Entity type:Organization
Organization Name:REDEFINE YOUR SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-563-7601
Mailing Address - Street 1:11012 N DALE MABRY HWY STE 304
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-3821
Mailing Address - Country:US
Mailing Address - Phone:813-563-7600
Mailing Address - Fax:813-563-7601
Practice Address - Street 1:11012 N DALE MABRY HWY STE 304
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-3821
Practice Address - Country:US
Practice Address - Phone:813-563-7600
Practice Address - Fax:813-563-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-02
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty