Provider Demographics
NPI:1720037922
Name:WEST STATE ORTHOPEDICS AND SPORTS MEDICINE CLINIC
Entity Type:Organization
Organization Name:WEST STATE ORTHOPEDICS AND SPORTS MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:GRANGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-392-2330
Mailing Address - Street 1:506 S 6TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4442
Mailing Address - Country:US
Mailing Address - Phone:337-392-2330
Mailing Address - Fax:337-392-2580
Practice Address - Street 1:506 S 6TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4442
Practice Address - Country:US
Practice Address - Phone:337-392-2330
Practice Address - Fax:337-392-2580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11865R207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty