Provider Demographics
NPI:1396760096
Name:LISCUM, SAMUEL E (DC)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:E
Last Name:LISCUM
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 1:7304 OLSEN RD
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70665-7796
Mailing Address - Country:US
Mailing Address - Phone:337-439-7007
Mailing Address - Fax:337-439-7011
Practice Address - Street 1:24012 MAPLEWOOD DR
Practice Address - Street 2:SUITE 2
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663
Practice Address - Country:US
Practice Address - Phone:337-439-7007
Practice Address - Fax:337-439-7011
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1563111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U93007Medicare UPIN