1689915183 NPI number — INNATE POTENTIAL CHIROPRACTIC 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 1689915183 NPI number — INNATE POTENTIAL CHIROPRACTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNATE POTENTIAL CHIROPRACTIC 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:
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:
1689915183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60154 NINA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LACOMBE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70445-3938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-900-4210
Provider Business Mailing Address Fax Number:
504-335-0740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2163 GAUSE BLVD W STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SLIDELL
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70460-4132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-250-4465
Provider Business Practice Location Address Fax Number:
504-335-0740
Provider Enumeration Date:
03/07/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
JONNY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
985-900-4210

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1661 , 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: 1891048344 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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