Provider Demographics
NPI:1891122594
Name:ULTIMATE PERFORMANCE CHIROPRACTIC & REHAB, LLC
Entity Type:Organization
Organization Name:ULTIMATE PERFORMANCE CHIROPRACTIC & REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAIGLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:337-421-0010
Mailing Address - Street 1:646 W. MCNEESE STREET
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605
Mailing Address - Country:US
Mailing Address - Phone:337-421-0010
Mailing Address - Fax:337-421-0032
Practice Address - Street 1:646 W. MCNEESE STREET
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605
Practice Address - Country:US
Practice Address - Phone:337-421-0010
Practice Address - Fax:337-421-0032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1658111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty