Provider Demographics
NPI:1891859500
Name:HOUMA-THIBODAUX SPINE AND REHABILITATION LLC
Entity Type:Organization
Organization Name:HOUMA-THIBODAUX SPINE AND REHABILITATION LLC
Other - Org Name:THIBODAUX INJURY & REHABILITATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:I
Authorized Official - Last Name:PORCHE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:985-873-8586
Mailing Address - Street 1:430 CORPORATE DR.
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360
Mailing Address - Country:US
Mailing Address - Phone:985-873-8586
Mailing Address - Fax:985-873-8565
Practice Address - Street 1:430 CORPORATE DR.
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360
Practice Address - Country:US
Practice Address - Phone:985-873-8586
Practice Address - Fax:985-873-8565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1380111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty