Provider Demographics
NPI:1992884217
Name:LORDEX SPINE CENTER OF COLUMBIA P.C.
Entity type:Organization
Organization Name:LORDEX SPINE CENTER OF COLUMBIA P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BROOKS
Authorized Official - Middle Name:M
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:573-443-0551
Mailing Address - Street 1:3400 BUTTONWOOD DR
Mailing Address - Street 2:STE C
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-3720
Mailing Address - Country:US
Mailing Address - Phone:573-443-0551
Mailing Address - Fax:573-442-2959
Practice Address - Street 1:3400 BUTTONWOOD DR
Practice Address - Street 2:STE C
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-3720
Practice Address - Country:US
Practice Address - Phone:573-443-0551
Practice Address - Fax:573-442-2959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002023835204C00000X
MOR8620204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000414663Medicare ID - Type UnspecifiedMEDICARE PROVIDER #