Provider Demographics
NPI:1891252300
Name:1469LLC
Entity Type:Organization
Organization Name:1469LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIPLOMATE OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:SYLVI
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUMONT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:504-864-1234
Mailing Address - Street 1:1138 S CARROLLTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-2024
Mailing Address - Country:US
Mailing Address - Phone:504-864-1234
Mailing Address - Fax:
Practice Address - Street 1:1138 S CARROLLTON AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-2024
Practice Address - Country:US
Practice Address - Phone:504-864-1234
Practice Address - Fax:504-864-1239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-21
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAG0969OtherBLUE CROSS BLUE SHIELD