Provider Demographics
NPI:1184631210
Name:CENTER FOR NEUROSURGICAL AND SPINE DISORDERS, LLC
Entity Type:Organization
Organization Name:CENTER FOR NEUROSURGICAL AND SPINE DISORDERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEE
Authorized Official - Middle Name:F
Authorized Official - Last Name:HARLESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-478-9653
Mailing Address - Street 1:PO BOX 1786
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-1786
Mailing Address - Country:US
Mailing Address - Phone:337-478-9653
Mailing Address - Fax:337-474-0988
Practice Address - Street 1:1614 WOLF CIR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2348
Practice Address - Country:US
Practice Address - Phone:337-478-9653
Practice Address - Fax:337-474-0988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021935207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1567949Medicaid
LA1436461Medicaid
LAG91984Medicare UPIN
LA5CA84Medicare ID - Type Unspecified
LA1567949Medicaid
LA1436461Medicaid
LA4B599Medicare ID - Type Unspecified