Provider Demographics
NPI:1245491695
Name:SHREVEPORT CHIROPRACTIC
Entity type:Organization
Organization Name:SHREVEPORT CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GRADY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:STIMITS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-429-9494
Mailing Address - Street 1:1845 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4611
Mailing Address - Country:US
Mailing Address - Phone:318-429-9494
Mailing Address - Fax:318-429-9492
Practice Address - Street 1:1845 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4611
Practice Address - Country:US
Practice Address - Phone:318-429-9494
Practice Address - Fax:318-429-9492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1264111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4362770100OtherBLUE CROSS/BLUE SHIELD OF LOUISIANA