1124521380 NPI number — 100 PERCENT CHIROPRACTIC

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 1124521380 NPI number — 100 PERCENT CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
100 PERCENT CHIROPRACTIC
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:
1124521380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 E PRIEN LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CHARLES
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70601-7976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-477-0600
Provider Business Mailing Address Fax Number:
337-474-4935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 E PRIEN LAKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70601-7976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-477-0600
Provider Business Practice Location Address Fax Number:
337-474-4935
Provider Enumeration Date:
03/14/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ROUSH
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
JANELLE
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
337-477-0600

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111NP0017X , 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: 1363 . This is a "LOUISIANA STATE BOARD OF CHIROPRACTIC EXAMINERS" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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