Provider Demographics
NPI:1821187105
Name:PREWITT, RICKEY LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:RICKEY
Middle Name:LYNN
Last Name:PREWITT
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 1:3121 VAN BUREN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-3452
Mailing Address - Country:US
Mailing Address - Phone:225-774-5566
Mailing Address - Fax:225-774-8855
Practice Address - Street 1:3121 VAN BUREN ST
Practice Address - Street 2:SUITE B
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-3452
Practice Address - Country:US
Practice Address - Phone:225-774-5566
Practice Address - Fax:225-774-8855
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA800111N00000X
AR1169111N00000X
TN608111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1955604Medicaid
LA10984758OtherCAQH
LA4770113OtherCIGNA
LA10984758OtherCAQH
LA59485D728Medicare PIN