Provider Demographics
NPI:1659569119
Name:MOSS BLUFF CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:MOSS BLUFF CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:337-855-6306
Mailing Address - Street 1:PO BOX 12571
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70612-2571
Mailing Address - Country:US
Mailing Address - Phone:337-855-6306
Mailing Address - Fax:337-855-7012
Practice Address - Street 1:119 TAHOE DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-5109
Practice Address - Country:US
Practice Address - Phone:337-855-6306
Practice Address - Fax:337-855-7012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CB99Medicare PIN
LAU37091Medicare UPIN