Provider Demographics
NPI:1578751889
Name:CHIRO/PRACTICAL
Entity Type:Organization
Organization Name:CHIRO/PRACTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SIMONSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:225-658-0500
Mailing Address - Street 1:5626 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-4023
Mailing Address - Country:US
Mailing Address - Phone:225-658-0500
Mailing Address - Fax:225-658-9414
Practice Address - Street 1:5626 MAIN ST
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4023
Practice Address - Country:US
Practice Address - Phone:225-658-0500
Practice Address - Fax:225-658-9414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1211111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CD95Medicare PIN