Provider Demographics
NPI:1174802532
Name:ENVISTA MEDICAL NECK AND BACK CENTER, P.C.
Entity type:Organization
Organization Name:ENVISTA MEDICAL NECK AND BACK CENTER, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-587-0700
Mailing Address - Street 1:3900 COFFEE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93308-5050
Mailing Address - Country:US
Mailing Address - Phone:661-587-0700
Mailing Address - Fax:661-587-9131
Practice Address - Street 1:3900 COFFEE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-5049
Practice Address - Country:US
Practice Address - Phone:661-587-0700
Practice Address - Fax:661-587-9131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC22958111N00000X
207LP2900X, 208100000X
CAPA17041363AM0700X
CADC13886111N00000X
CADC30202111N00000X
CADC30545111N00000X
CA20A6314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ69252ZOtherBLUE SHIELD OF CALIFORNIA
CA1174802532OtherGROUP NPI