# SOUTHEAST SPINE CENTER, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1295008712
- **Authorized official:** MR. GEORGE J IVANICKY (OWNER/PRESIDENT)
- **Authorized official phone:** (225) 753-6333

## Contact information

- **Practice address:** 17431 JEFFERSON HWY, SUITE A, BATON ROUGE, LA 70817-7484
- **Practice address phone:** (225) 753-6333
- **Practice address fax:** (225) 753-6336
- **Mailing address:** 17431 JEFFERSON HWY, SUITE A, BATON ROUGE, LA 70817-7484
- **Mailing address phone:** (225) 753-6333
- **Mailing address fax:** (225) 753-6336

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | NULL | Yes |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | — | Yes |
| 225100000X | Physical Therapist | — | NULL | — |
| 225100000X | Physical Therapist | — | — | — |

## Other

- **Enumeration date:** 02/14/2012
- **Last updated:** 02/14/2012