Provider Demographics
NPI:1417164310
Name:BOURGEOIS, CATHERINE ANN (DR)
Entity Type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:ANN
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 SE 14TH STREET #2
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712
Mailing Address - Country:US
Mailing Address - Phone:479-271-6992
Mailing Address - Fax:479-271-6993
Practice Address - Street 1:1300 SE 14TH ST # 2
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6814
Practice Address - Country:US
Practice Address - Phone:479-271-6992
Practice Address - Fax:479-271-6993
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1350111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT95762Medicare UPIN