MEDICARE: WEST STATE ORTHOPEDICS AND SPORTS MEDICINE CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	11865R	LA

General Provider Information

NPI Number	:	1720037922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST STATE ORTHOPEDICS AND SPORTS MEDICINE CLINIC

Provider Business Mailing Address
First Line	:	506 S 6TH ST
Second Line	:	SUITE B
City	:	LEESVILLE
State	:	LA
Zip	:	71446-4442
Country	:	US
Telephone Number	:	337-392-2330
Fax Number	:	337-392-2580

Provider Business Practice Location Address
First Line	:	506 S 6TH ST
Second Line	:	SUITE B
City	:	LEESVILLE
State	:	LA
Zip	:	71446-4442
Country	:	US
Telephone Number	:	337-392-2330
Fax Number	:	337-392-2580

Authorized Official
Title or Position	:	PHYSICIAN / OWNER
Name	:	SHAWN PATRICK GRANGER
Credential	:	M.D.
Telephone Number	:	337-392-2330

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	08/22/2020

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