Provider Demographics
NPI:1124125109
Name:INSTITUTE FOR LOW BACK CARE LLC
Entity type:Organization
Organization Name:INSTITUTE FOR LOW BACK CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PANJINI
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIVANNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-297-0817
Mailing Address - Street 1:300 MAIN AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1930
Mailing Address - Country:US
Mailing Address - Phone:701-297-0817
Mailing Address - Fax:701-297-6870
Practice Address - Street 1:300 MAIN AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1930
Practice Address - Country:US
Practice Address - Phone:701-297-0817
Practice Address - Fax:701-297-6870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4806174400000X, 261QA1903X
261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND6826334Medicaid
ND6826334Medicaid