Provider Demographics
NPI:1609953843
Name:CHAGNON, DOMINIQUE ROCH (DC)
Entity Type:Individual
Prefix:MR
First Name:DOMINIQUE
Middle Name:ROCH
Last Name:CHAGNON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6935 OLD CANTON RD
Mailing Address - Street 2:STE A
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157
Mailing Address - Country:US
Mailing Address - Phone:601-956-6050
Mailing Address - Fax:601-952-0738
Practice Address - Street 1:6935 OLD CANTON RD
Practice Address - Street 2:STE A
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157
Practice Address - Country:US
Practice Address - Phone:601-956-6050
Practice Address - Fax:601-952-0738
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0875111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114952Medicaid
MS09015779Medicaid
MSC03216Medicare ID - Type UnspecifiedGROUP
U35152Medicare UPIN