1649792318 NPI number — DYNAMIC PERFORMANCE CHIROPRACTIC OF BATON ROUGE

Table of content: (NPI 1649792318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649792318 NPI number — DYNAMIC PERFORMANCE CHIROPRACTIC OF BATON ROUGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC PERFORMANCE CHIROPRACTIC OF BATON ROUGE
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:
1649792318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32350 LA HIGHWAY 16 BLDG C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENHAM SPRINGS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70726-1463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-664-1456
Provider Business Mailing Address Fax Number:
866-766-9895

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5151 PLANK RD STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70805-3501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-664-1456
Provider Business Practice Location Address Fax Number:
866-766-9895
Provider Enumeration Date:
07/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BOURG
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER/CHIROPRACTOR
Authorized Official Telephone Number:
225-664-1456

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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