Provider Demographics
NPI:1255168175
Name:SOUTHERN SPINE & ORTHOPAEDICS LLC
Entity type:Organization
Organization Name:SOUTHERN SPINE & ORTHOPAEDICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-706-1142
Mailing Address - Street 1:105 PATRIOT ST STE 101
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6831
Mailing Address - Country:US
Mailing Address - Phone:337-981-2125
Mailing Address - Fax:337-981-2174
Practice Address - Street 1:105 PATRIOT ST STE 101
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6831
Practice Address - Country:US
Practice Address - Phone:337-981-2125
Practice Address - Fax:337-981-2174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty