Provider Demographics
NPI:1629111661
Name:11TH STREET CHIROPRACTIC CLINIC, LLC
Entity Type:Organization
Organization Name:11TH STREET CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BUFFIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROME
Authorized Official - Suffix:VI
Authorized Official - Credentials:
Authorized Official - Phone:504-467-0302
Mailing Address - Street 1:1919 VETERANS BOULEVARD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70062
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 N 11TH ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-2212
Practice Address - Country:US
Practice Address - Phone:409-838-0909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty