Provider Demographics
NPI:1356869069
Name:HUMBLE, DALLAS (DC)
Entity type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:
Last Name:HUMBLE
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 1:410 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-4108
Mailing Address - Country:US
Mailing Address - Phone:318-303-6142
Mailing Address - Fax:318-855-8453
Practice Address - Street 1:801 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-4534
Practice Address - Country:US
Practice Address - Phone:318-303-6142
Practice Address - Fax:318-855-8453
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA488111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1951731Medicaid