Basic Information
| Provider Information | |||||||||
| NPI: | 1366196461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMAC MEDICAL OF LOUISIANA A MEDICAL CORPORATION | ||||||||
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| OtherOrganizationName: | LOUISIANA ORTHOPEDIC & SPINE INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 WESTGATE CIR STE 100 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370278396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8442664622 | ||||||||
| FaxNumber: | 6156377334 | ||||||||
| Practice Location | |||||||||
| Address1: | 1940 ONEAL LN | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708163201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885533689 | ||||||||
| FaxNumber: | 2257516680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2022 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | BOYETT | ||||||||
| AuthorizedOfficialFirstName: | BAILEE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6156377333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | N | Ambulatory Health Care Facilities | Clinic/Center | Pain | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.