Healthcare Provider Details

I. General information

NPI: 1538780630
Provider Name (Legal Business Name): CENTER FOR ORTHOPAEDICS AND SPINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 IMPERIAL BLVD BLDG 1B
LAKE CHARLES LA
70605-5392
US

IV. Provider business mailing address

1747 IMPERIAL BLVD
LAKE CHARLES LA
70605-5362
US

V. Phone/Fax

Practice location:
  • Phone: 337-721-7236
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
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: 337-721-7242