Provider Demographics
NPI:1558612267
Name:SOUTHERLAND SPINE CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHERLAND SPINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:DREW
Authorized Official - Last Name:SOUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:423-748-0506
Mailing Address - Street 1:1092 JOHNNIE DODDS BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-6109
Mailing Address - Country:US
Mailing Address - Phone:843-654-5151
Mailing Address - Fax:843-654-5111
Practice Address - Street 1:1092 JOHNNIE DODDS BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-6109
Practice Address - Country:US
Practice Address - Phone:843-654-5151
Practice Address - Fax:843-654-5111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty