1457850158 NPI number — DYNAMIC PERFORMANCE CHIROPRACTIC OF HAMMOND

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457850158 NPI number — DYNAMIC PERFORMANCE CHIROPRACTIC OF HAMMOND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC PERFORMANCE CHIROPRACTIC OF HAMMOND
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:
Provider Other Organization Name Type Code:
6
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:
1457850158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17557 OLD JEFFERSON HWY
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
PRAIRIEVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70769
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-402-0260
Provider Business Mailing Address Fax Number:
225-744-8201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1330 SOUTH MAGNOLIA
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
HAMMOND
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-402-0260
Provider Business Practice Location Address Fax Number:
225-744-8201
Provider Enumeration Date:
02/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SHELLY
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
985-400-1633

Provider Taxonomy Codes

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

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





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