Provider Demographics
NPI:1982857561
Name:FAIRCLOTH CHIROPRACTIC CLINIC, L.L.C.
Entity Type:Organization
Organization Name:FAIRCLOTH CHIROPRACTIC CLINIC, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:BOISVERT
Authorized Official - Last Name:FAIRCLOTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-448-8462
Mailing Address - Street 1:3620 BAYOU RAPIDES RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3653
Mailing Address - Country:US
Mailing Address - Phone:318-448-8462
Mailing Address - Fax:318-448-8486
Practice Address - Street 1:3620 BAYOU RAPIDES RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3653
Practice Address - Country:US
Practice Address - Phone:318-448-8462
Practice Address - Fax:318-448-8486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA915111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty