Provider Demographics
NPI:1346495520
Name:LOUISA CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:LOUISA CHIROPRACTIC CENTER, LLC
Other - Org Name:LOUISA CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:540-967-2522
Mailing Address - Street 1:506 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:VA
Mailing Address - Zip Code:23093-4100
Mailing Address - Country:US
Mailing Address - Phone:540-967-2522
Mailing Address - Fax:540-967-5878
Practice Address - Street 1:506 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:VA
Practice Address - Zip Code:23093-4100
Practice Address - Country:US
Practice Address - Phone:540-967-2522
Practice Address - Fax:540-967-5878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01040000734111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010100089Medicaid
VA01040000734OtherSTATE LICENSE TO PRACTICE
VAT94040Medicare UPIN
VA010100089Medicaid