Basic Information
| Provider Information | |||||||||
| NPI: | 1538780630 | ||||||||
| 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 | ||||||||
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| Address1: | 1727 IMPERIAL BLVD BLDG 1B | ||||||||
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| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706055392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377217236 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2020 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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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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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207RR0500X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
No ID Information.