Healthcare Provider Details

I. General information

NPI: 1295008712
Provider Name (Legal Business Name): SOUTHEAST SPINE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17431 JEFFERSON HWY SUITE A
BATON ROUGE LA
70817-7484
US

IV. Provider business mailing address

17431 JEFFERSON HWY SUITE A
BATON ROUGE LA
70817-7484
US

V. Phone/Fax

Practice location:
  • Phone: 225-753-6333
  • Fax: 225-753-6336
Mailing address:
  • Phone: 225-753-6333
  • Fax: 225-753-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. GEORGE J IVANICKY
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 225-753-6333