Provider Demographics
NPI:1720174170
Name:RICHARD, CHAD (DC)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:RICHARD
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 1:119 TAHOE DR
Mailing Address - Street 2:PO BOX 12571
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70611-5109
Mailing Address - Country:US
Mailing Address - Phone:337-855-6306
Mailing Address - Fax:337-855-7012
Practice Address - Street 1:MOSS BLUFF CHIROPRACTIC CLINIC 119 TAHOE DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-5109
Practice Address - Country:US
Practice Address - Phone:337-855-6306
Practice Address - Fax:337-855-7012
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA954111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CB99Medicare PIN
LAU37091Medicare UPIN