Provider Demographics
NPI: | 1750485751 |
---|---|
Name: | LORDEX SPINE INSTITUTE |
Entity Type: | Organization |
Organization Name: | LORDEX SPINE INSTITUTE |
Other - Org Name: | LORDEX SPINE INSTITUTE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | SUPERVISOR |
Authorized Official - Prefix: | MISS |
Authorized Official - First Name: | MILDRED |
Authorized Official - Middle Name: | JEAN |
Authorized Official - Last Name: | LEE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PT |
Authorized Official - Phone: | 850-862-5588 |
Mailing Address - Street 1: | 928 MAR WALT DRIVE E |
Mailing Address - Street 2: | SUITE 201 |
Mailing Address - City: | FORT WALTON BEACH |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32547 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 850-862-5588 |
Mailing Address - Fax: | 850-862-6015 |
Practice Address - Street 1: | 928 MAR WALT DRIVE E |
Practice Address - Street 2: | SUITE 201 |
Practice Address - City: | FORT WALTON BEACH |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32547 |
Practice Address - Country: | US |
Practice Address - Phone: | 850-862-5588 |
Practice Address - Fax: | 850-862-6015 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-09-11 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |