Healthcare Provider Details

I. General information

NPI: 1184631210
Provider Name (Legal Business Name): CENTER FOR NEUROSURGICAL AND SPINE DISORDERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1614 WOLF CIR
LAKE CHARLES LA
70605-2348
US

IV. Provider business mailing address

PO BOX 1786
LAKE CHARLES LA
70602-1786
US

V. Phone/Fax

Practice location:
  • Phone: 337-478-9653
  • Fax: 337-474-0988
Mailing address:
  • Phone: 337-478-9653
  • Fax: 337-474-0988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number021935
License Number StateLA

VIII. Authorized Official

Name: DEE F HARLESS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 337-478-9653