Provider Demographics
NPI:1629294863
Name:CHILDRESS, EARL ATWOOD (DC)
Entity Type:Individual
Prefix:DR
First Name:EARL
Middle Name:ATWOOD
Last Name:CHILDRESS
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 1:605 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:LA
Mailing Address - Zip Code:71232-3101
Mailing Address - Country:US
Mailing Address - Phone:318-878-3778
Mailing Address - Fax:318-878-3779
Practice Address - Street 1:605 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:DELHI
Practice Address - State:LA
Practice Address - Zip Code:71232-3101
Practice Address - Country:US
Practice Address - Phone:318-878-3778
Practice Address - Fax:318-878-3779
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA306111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA59050Medicare ID - Type Unspecified