Provider Demographics
NPI:1134650708
Name:FREEDOM SPINE, LLC
Entity Type:Organization
Organization Name:FREEDOM SPINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-871-4114
Mailing Address - Street 1:29301 N DIXIE RANCH RD
Mailing Address - Street 2:
Mailing Address - City:LACOMBE
Mailing Address - State:LA
Mailing Address - Zip Code:70445-5403
Mailing Address - Country:US
Mailing Address - Phone:985-871-4114
Mailing Address - Fax:985-871-4130
Practice Address - Street 1:29301 N DIXIE RANCH RD
Practice Address - Street 2:
Practice Address - City:LACOMBE
Practice Address - State:LA
Practice Address - Zip Code:70445-5403
Practice Address - Country:US
Practice Address - Phone:985-871-4114
Practice Address - Fax:985-871-4130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.020254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAF63325Medicare UPIN