Healthcare Provider Details

I. General information

NPI: 1760520449
Provider Name (Legal Business Name): NECK AND BACK CLINIC OF KINDER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 1ST AVE
KINDER LA
70648
US

IV. Provider business mailing address

POB 910
KINDER LA
70648
US

V. Phone/Fax

Practice location:
  • Phone: 337-738-4118
  • Fax: 337-738-5604
Mailing address:
  • Phone: 337-738-4118
  • Fax: 337-738-5604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number986
License Number StateLA

VIII. Authorized Official

Name: JEFFREY LEE DAVIS
Title or Position: PRESIDENT
Credential: DC
Phone: 337-738-4118