Provider Demographics
NPI:1801999057
Name:SPINE & SPORTS SPECIALTIES
Entity type:Organization
Organization Name:SPINE & SPORTS SPECIALTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, ATC, CSCS
Authorized Official - Phone:225-647-1515
Mailing Address - Street 1:PO BOX 1991
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70707-1991
Mailing Address - Country:US
Mailing Address - Phone:225-647-1515
Mailing Address - Fax:225-647-5151
Practice Address - Street 1:2012 S. BURNSIDE AVE.
Practice Address - Street 2:SUITE B
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4637
Practice Address - Country:US
Practice Address - Phone:225-647-1515
Practice Address - Fax:225-647-5151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty