Provider Demographics
NPI:1366780496
Name:INTERVENTIONAL SPINE CENTER LLC
Entity type:Organization
Organization Name:INTERVENTIONAL SPINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAHAT
Authorized Official - Middle Name:
Authorized Official - Last Name:FADERANI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-543-8888
Mailing Address - Street 1:150 SW 12TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-3298
Mailing Address - Country:US
Mailing Address - Phone:561-543-8888
Mailing Address - Fax:
Practice Address - Street 1:150 SW 12TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-3298
Practice Address - Country:US
Practice Address - Phone:561-543-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10474208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty