Provider Demographics
NPI:1609904861
Name:MAYFIELD CHRIOPRACTIC WEST INC
Entity Type:Organization
Organization Name:MAYFIELD CHRIOPRACTIC WEST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-396-5558
Mailing Address - Street 1:PO BOX 2274
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71294-2274
Mailing Address - Country:US
Mailing Address - Phone:318-396-5558
Mailing Address - Fax:318-396-9119
Practice Address - Street 1:4900 CYPRESS ST
Practice Address - Street 2:SIUTE 13
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7670
Practice Address - Country:US
Practice Address - Phone:318-396-5558
Practice Address - Fax:318-396-9119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1352111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4050634820OtherBLUE CROSS BLUE SHIELD LA
LAV03213Medicare UPIN
LA5CN28Medicare ID - Type UnspecifiedGROUP NUMBER