Provider Demographics
NPI:1467496125
Name:DEEP SOUTH CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:DEEP SOUTH CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:337-238-0027
Mailing Address - Street 1:105 WARNER STREET
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446
Mailing Address - Country:US
Mailing Address - Phone:337-238-0027
Mailing Address - Fax:337-238-0227
Practice Address - Street 1:105 WARNER ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-2821
Practice Address - Country:US
Practice Address - Phone:337-238-0027
Practice Address - Fax:337-238-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1168111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========OtherTAX IDENTIFICATION
LA5X956Medicare PIN