Healthcare Provider Details

I. General information

NPI: 1013517762
Provider Name (Legal Business Name): CENTER FOR ORTHOPAEDICS AND SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 10/30/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 NELSON RD STE C11
LAKE CHARLES LA
70605-4133
US

IV. Provider business mailing address

1747 IMPERIAL BLVD
LAKE CHARLES LA
70605-5362
US

V. Phone/Fax

Practice location:
  • Phone: 337-312-8617
  • Fax: 337-721-2939
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN WALLACE NOBLE
Title or Position: MANAGER MEMBER
Credential: MD
Phone: 337-721-7236