Provider Demographics
NPI:1972051548
Name:DYNAMIC SPINAL IMAGING OF SWLA, LLC
Entity Type:Organization
Organization Name:DYNAMIC SPINAL IMAGING OF SWLA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CONDOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:337-602-6300
Mailing Address - Street 1:805 W BAYOU PINES DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-9605
Mailing Address - Country:US
Mailing Address - Phone:337-602-6300
Mailing Address - Fax:337-602-6339
Practice Address - Street 1:805 W BAYOU PINES DR
Practice Address - Street 2:SUITE D
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-9605
Practice Address - Country:US
Practice Address - Phone:337-602-6300
Practice Address - Fax:337-602-6339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain