Provider Demographics
NPI:1609331438
Name:PASS CHRISTIAN CHIROMED, LLC
Entity Type:Organization
Organization Name:PASS CHRISTIAN CHIROMED, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BOURGEIOS
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:228-865-9898
Mailing Address - Street 1:PO BOX 2563
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-2563
Mailing Address - Country:US
Mailing Address - Phone:228-865-9898
Mailing Address - Fax:228-863-5616
Practice Address - Street 1:213 HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-4309
Practice Address - Country:US
Practice Address - Phone:228-865-9898
Practice Address - Fax:228-863-5616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty