Provider Demographics
NPI:1790095990
Name:ROGER CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:ROGER CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:337-237-2224
Mailing Address - Street 1:248 N COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4245
Mailing Address - Country:US
Mailing Address - Phone:337-237-2224
Mailing Address - Fax:337-237-2227
Practice Address - Street 1:248 N COLLEGE RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4245
Practice Address - Country:US
Practice Address - Phone:337-237-2224
Practice Address - Fax:337-237-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA385111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAT75550Medicare UPIN
LA59373Medicare PIN