Provider Demographics
NPI:1437924669
Name:SPINE SPORTS SURGERY CENTER, LLC
Entity type:Organization
Organization Name:SPINE SPORTS SURGERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERMAN
Authorized Official - Middle Name:NAM
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-378-6773
Mailing Address - Street 1:429 LLEWELLYN AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1948
Mailing Address - Country:US
Mailing Address - Phone:408-378-6773
Mailing Address - Fax:
Practice Address - Street 1:3803 S BASCOM AVE STE 106
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-7317
Practice Address - Country:US
Practice Address - Phone:408-520-4295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-17
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical