MEDICARE: DYNAMIC SPINAL IMAGING OF SWLA, LLC

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	261QP3300X	Pain Clinic/Center
2	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1972051548
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC SPINAL IMAGING OF SWLA, LLC

Provider Business Mailing Address
First Line	:	805 W BAYOU PINES DR
Second Line	:	SUITE D
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-9605
Country	:	US
Telephone Number	:	337-602-6300
Fax Number	:	337-602-6339

Provider Business Practice Location Address
First Line	:	805 W BAYOU PINES DR
Second Line	:	SUITE D
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-9605
Country	:	US
Telephone Number	:	337-602-6300
Fax Number	:	337-602-6339

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN R CONDOS
Credential	:	PHD
Telephone Number	:	337-602-6300

Provider Enumeration Date	:	09/13/2016
Last Update Date	:	09/13/2016

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