Provider Demographics
NPI:1295832624
Name:THIBODEAUX, BENJAMIN TODD (DC)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:TODD
Last Name:THIBODEAUX
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:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-0097
Mailing Address - Country:US
Mailing Address - Phone:337-945-7115
Mailing Address - Fax:
Practice Address - Street 1:1501 REES ST
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-4309
Practice Address - Country:US
Practice Address - Phone:337-332-2225
Practice Address - Fax:337-332-6097
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1278111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1295832624OtherBLUE CROSS BLUE SHIELD
LAU88810Medicare UPIN
4C108Medicare PIN