Provider Demographics
NPI:1609134501
Name:AMERICAN SPINE, PC
Entity type:Organization
Organization Name:AMERICAN SPINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KHURAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-276-7246
Mailing Address - Street 1:PO BOX 3098
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3098
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:39765 DATE ST
Practice Address - Street 2:101
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-2005
Practice Address - Country:US
Practice Address - Phone:951-734-7246
Practice Address - Fax:877-694-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90421207L00000X
208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6882920002OtherMEDICARE DMEPOS
CA6882920002OtherMEDICARE DMEPOS