Provider Demographics
NPI:1578731436
Name:WELLNESS MANAGEMENT CHIROPRACTIC AND MEDICAL CLINIC INC.
Entity Type:Organization
Organization Name:WELLNESS MANAGEMENT CHIROPRACTIC AND MEDICAL CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVIGNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-433-1919
Mailing Address - Street 1:2121 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7103
Mailing Address - Country:US
Mailing Address - Phone:337-433-1919
Mailing Address - Fax:
Practice Address - Street 1:2121 LAKE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7103
Practice Address - Country:US
Practice Address - Phone:337-433-1919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1137111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5CD26Medicare PIN