=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982834966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINE INSTITUTE OF SOUTHWEST LOUISIANA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2009
-----------------------------------------------------
Last Update Date | 07/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 W SAINT MARY BLVD SUITE 416
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70506-4600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-304-2752
-----------------------------------------------------
Fax | 504-324-3416
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 W SAINT MARY BLVD SUITE 416
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70506-4600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-304-2752
-----------------------------------------------------
Fax | 504-324-3416
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / OPERATOR
-----------------------------------------------------
Name | DR. KEVIN J LASSEIGNE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 504-304-2752
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 203148
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------