Provider Demographics
NPI:1477689305
Name:SPINE CLINIC OF BATON ROUGE
Entity Type:Organization
Organization Name:SPINE CLINIC OF BATON ROUGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:IVANICKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-766-5050
Mailing Address - Street 1:5211 ESSEN LN
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3564
Mailing Address - Country:US
Mailing Address - Phone:225-766-5050
Mailing Address - Fax:225-766-2052
Practice Address - Street 1:5211 ESSEN LN
Practice Address - Street 2:SUITE 1
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3564
Practice Address - Country:US
Practice Address - Phone:225-766-5050
Practice Address - Fax:225-766-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024904225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty