1609904861 NPI number — MAYFIELD CHRIOPRACTIC WEST INC

Table of content: (NPI 1609904861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609904861 NPI number — MAYFIELD CHRIOPRACTIC WEST INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAYFIELD CHRIOPRACTIC WEST INC
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:
1609904861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2274
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71294-2274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-396-5558
Provider Business Mailing Address Fax Number:
318-396-9119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4900 CYPRESS ST
Provider Second Line Business Practice Location Address:
SIUTE 13
Provider Business Practice Location Address City Name:
WEST MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71291-7670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-396-5558
Provider Business Practice Location Address Fax Number:
318-396-9119
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAYFIELD
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
318-396-5558

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1352 , 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)

  • Identifier: 4050634820 . This is a "BLUE CROSS BLUE SHIELD LA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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