Provider Demographics
NPI:1154467942
Name:TARVIN, KERRY DEE (DC)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:DEE
Last Name:TARVIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3431 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-3812
Mailing Address - Country:US
Mailing Address - Phone:318-425-2225
Mailing Address - Fax:318-425-2221
Practice Address - Street 1:3431 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-3812
Practice Address - Country:US
Practice Address - Phone:318-425-2225
Practice Address - Fax:318-425-2221
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1060LA111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5T-754Medicare ID - Type Unspecified