Provider Demographics
NPI:1649792318
Name:DYNAMIC PERFORMANCE CHIROPRACTIC OF BATON ROUGE
Entity type:Organization
Organization Name:DYNAMIC PERFORMANCE CHIROPRACTIC OF BATON ROUGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:225-664-1456
Mailing Address - Street 1:32350 LA HIGHWAY 16 BLDG C
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-1463
Mailing Address - Country:US
Mailing Address - Phone:225-664-1456
Mailing Address - Fax:866-766-9895
Practice Address - Street 1:5151 PLANK RD STE 220
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-3501
Practice Address - Country:US
Practice Address - Phone:225-664-1456
Practice Address - Fax:866-766-9895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty