Provider Demographics
NPI:1255461588
Name:HIGGINBOTHAM, GARY P (DC)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:P
Last Name:HIGGINBOTHAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 N TRENTON ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3324
Mailing Address - Country:US
Mailing Address - Phone:318-251-2424
Mailing Address - Fax:318-251-9922
Practice Address - Street 1:712 N TRENTON ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3324
Practice Address - Country:US
Practice Address - Phone:318-251-2424
Practice Address - Fax:318-251-9922
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA959111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5T496Medicare PIN