1790712214 NPI number — SPINE DIAGNOSTIC CENTER OF BATON ROUGE, INC A PROFESSIONAL MEDICAL COR

Table of content: (NPI 1790712214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790712214 NPI number — SPINE DIAGNOSTIC CENTER OF BATON ROUGE, INC A PROFESSIONAL MEDICAL COR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE DIAGNOSTIC CENTER OF BATON ROUGE, INC A PROFESSIONAL MEDICAL COR
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:
6
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:
1790712214
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 84128
Provider Second Line Business Mailing Address:
10523 N OAK HILL PKWY STE. B
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70884-4128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-769-1786
Provider Business Mailing Address Fax Number:
225-769-1766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5408 FLANDERS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70808-9168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-769-5554
Provider Business Practice Location Address Fax Number:
225-769-3334
Provider Enumeration Date:
06/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARGIL
Authorized Official First Name:
DANETTE
Authorized Official Middle Name:
TAYLOR
Authorized Official Title or Position:
OPERATIONS MANAGER
Authorized Official Telephone Number:
225-769-1786

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  17228 , 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)





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