Provider Demographics
NPI:1306304050
Name:SPINAL REGENERATION CENTER OF LA, LLC
Entity type:Organization
Organization Name:SPINAL REGENERATION CENTER OF LA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AUDITOR
Authorized Official - Prefix:
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAYLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-642-0884
Mailing Address - Street 1:70380 HIGHWAY 21 STE 2
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-8128
Mailing Address - Country:US
Mailing Address - Phone:504-577-3035
Mailing Address - Fax:
Practice Address - Street 1:2225 N HULLEN ST
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-1929
Practice Address - Country:US
Practice Address - Phone:504-944-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty