1720037922 NPI number — WEST STATE ORTHOPEDICS AND SPORTS MEDICINE CLINIC

Table of content: (NPI 1720037922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720037922 NPI number — WEST STATE ORTHOPEDICS AND SPORTS MEDICINE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST STATE ORTHOPEDICS AND SPORTS MEDICINE CLINIC
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:
Provider Other Organization Name Type Code:
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:
1720037922
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
506 S 6TH ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
LEESVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71446-4442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-392-2330
Provider Business Mailing Address Fax Number:
337-392-2580

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 S 6TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LEESVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71446-4442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-392-2330
Provider Business Practice Location Address Fax Number:
337-392-2580
Provider Enumeration Date:
05/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRANGER
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
PHYSICIAN / OWNER
Authorized Official Telephone Number:
337-392-2330

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  11865R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com