Provider Demographics
NPI:1306193701
Name:RAWLS, JEREMY DAVID (DC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:RAWLS
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 364
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:LA
Mailing Address - Zip Code:71263-0364
Mailing Address - Country:US
Mailing Address - Phone:318-428-8450
Mailing Address - Fax:
Practice Address - Street 1:212 N FRONT ST
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:LA
Practice Address - Zip Code:71263
Practice Address - Country:US
Practice Address - Phone:318-428-8450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1648111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor