Basic Information
| Provider Information | |||||||||
| NPI: | 1326682089 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR ORTHOPAEDICS AND SPINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1747 IMPERIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706055362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377217236 | ||||||||
| FaxNumber: | 3377217237 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 BEGLIS PKWY STE 1 | ||||||||
| Address2: | |||||||||
| City: | SULPHUR | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706633503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3376262529 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2019 | ||||||||
| LastUpdateDate: | 02/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | NOBLE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | WALLACE | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3377217242 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2086S0105X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | 208VP0014X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.