Provider Demographics
NPI:1922006345
Name:MINIMALLY INVASIVE IMAGE GUIDED SPECIALISTS, LLC
Entity Type:Organization
Organization Name:MINIMALLY INVASIVE IMAGE GUIDED SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-442-8399
Mailing Address - Street 1:PO BOX 6285
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71307-6285
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3704 NORTH BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3606
Practice Address - Country:US
Practice Address - Phone:318-442-8399
Practice Address - Fax:318-448-9897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-09
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1447170Medicaid
LADC2064Medicare PIN
LA5CM41Medicare ID - Type Unspecified