1073689881 NPI number — UNDERWOOD UNDERWOOD LLC

Table of content: (NPI 1073689881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073689881 NPI number — UNDERWOOD UNDERWOOD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNDERWOOD UNDERWOOD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
UNDERWOOD CHIROPRACTIC CLINIC
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073689881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11851 COURSEY BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-293-1700
Provider Business Mailing Address Fax Number:
225-293-1774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11851 COURSEY BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-293-1700
Provider Business Practice Location Address Fax Number:
225-293-1774
Provider Enumeration Date:
11/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
UNDERWOOD
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
225-293-1700

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1160 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: 304 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G3181 . This is a "BLUE CROSS" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: G3179 . This is a "BLUE CROSS" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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