Provider Demographics
NPI:1790883783
Name:CENTRAL CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:CENTRAL CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDLE
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:HAWTHORNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-281-0550
Mailing Address - Street 1:PO BOX 1462
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-1462
Mailing Address - Country:US
Mailing Address - Phone:318-281-0550
Mailing Address - Fax:318-283-1883
Practice Address - Street 1:608 N MARABLE ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-3032
Practice Address - Country:US
Practice Address - Phone:318-281-0550
Practice Address - Fax:318-283-1883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA293111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1935395Medicaid
T19893Medicare UPIN
LA1935395Medicaid