Provider Demographics
NPI:1295008712
Name:SOUTHEAST SPINE CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHEAST SPINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:IVANICKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-753-6333
Mailing Address - Street 1:17431 JEFFERSON HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-7484
Mailing Address - Country:US
Mailing Address - Phone:225-753-6333
Mailing Address - Fax:225-753-6336
Practice Address - Street 1:17431 JEFFERSON HWY
Practice Address - Street 2:SUITE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-7484
Practice Address - Country:US
Practice Address - Phone:225-753-6333
Practice Address - Fax:225-753-6336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty