1609040211 NPI number — SPINAL HEALTH CENTER OF NORTH LOUISIANA LLC

Table of content: MARK THOMAS DOMENICK MD (NPI 1770536476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609040211 NPI number — SPINAL HEALTH CENTER OF NORTH LOUISIANA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINAL HEALTH CENTER OF NORTH LOUISIANA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HEALTHSOURCE CHIROPRACTIC OF NORTH LOUISIANA LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609040211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3103 CYPRESS ST STE 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71291-5270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-322-2250
Provider Business Mailing Address Fax Number:
318-322-1114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3103 CYPRESS ST
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
WEST MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71291-5269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-322-2250
Provider Business Practice Location Address Fax Number:
318-322-1114
Provider Enumeration Date:
04/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
STEFFINS
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
318-322-2250

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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