1801307293 NPI number — MAYFIELD CHIROPRACTIC CLINIC BOSSIER LLC

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 1801307293 NPI number — MAYFIELD CHIROPRACTIC CLINIC BOSSIER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAYFIELD CHIROPRACTIC CLINIC BOSSIER 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:
Provider Other Organization Name Type Code:
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:
1801307293
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14923
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71207-4923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-512-5231
Provider Business Mailing Address Fax Number:
318-323-7265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2136 AIRLINE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111-3106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-828-1517
Provider Business Practice Location Address Fax Number:
318-828-1685
Provider Enumeration Date:
10/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MAYFIELD
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
318-512-5230

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1067 , 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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