Provider Demographics
NPI:1790712214
Name:SPINE DIAGNOSTIC CENTER OF BATON ROUGE, INC A PROFESSIONAL MEDICAL COR
Entity Type:Organization
Organization Name:SPINE DIAGNOSTIC CENTER OF BATON ROUGE, INC A PROFESSIONAL MEDICAL COR
Other - Org Name:THE SPINE DIAGNOSTIC AND PAIN TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANETTE
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:CARGIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-769-1786
Mailing Address - Street 1:PO BOX 84128
Mailing Address - Street 2:10523 N OAK HILL PKWY STE. B
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70884-4128
Mailing Address - Country:US
Mailing Address - Phone:225-769-1786
Mailing Address - Fax:225-769-1766
Practice Address - Street 1:5408 FLANDERS DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-9168
Practice Address - Country:US
Practice Address - Phone:225-769-5554
Practice Address - Fax:225-769-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17228174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty