Healthcare Provider Details

I. General information

NPI: 1134650708
Provider Name (Legal Business Name): FREEDOM SPINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29301 N DIXIE RANCH RD
LACOMBE LA
70445-5403
US

IV. Provider business mailing address

29301 N DIXIE RANCH RD
LACOMBE LA
70445-5403
US

V. Phone/Fax

Practice location:
  • Phone: 985-871-4114
  • Fax: 985-871-4130
Mailing address:
  • Phone: 985-871-4114
  • Fax: 985-871-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD.020254
License Number StateLA

VIII. Authorized Official

Name: DR. JOHN B LOGAN
Title or Position: OWNER
Credential: M.D.
Phone: 985-871-4114