Provider Demographics
NPI:1326706284
Name:SOUTHEAST SPINE AND PAIN CENTER LLC
Entity Type:Organization
Organization Name:SOUTHEAST SPINE AND PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:II
Authorized Official - Credentials:DC
Authorized Official - Phone:864-788-1002
Mailing Address - Street 1:205 CENTRAL PARK LN STE A
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-1156
Mailing Address - Country:US
Mailing Address - Phone:864-788-1002
Mailing Address - Fax:
Practice Address - Street 1:205 CENTRAL PARK LN STE A
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-1156
Practice Address - Country:US
Practice Address - Phone:864-788-1002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-07
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty