Healthcare Provider Details

I. General information

NPI: 1801057120
Provider Name (Legal Business Name): CAJUN SPINE AND SPORT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 W PINHOOK RD SUITE 211
LAFAYETTE LA
70508-3735
US

IV. Provider business mailing address

1602 W PINHOOK RD SUITE 211
LAFAYETTE LA
70508-3735
US

V. Phone/Fax

Practice location:
  • Phone: 337-261-2669
  • Fax:
Mailing address:
  • Phone: 337-261-2669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1467
License Number StateLA

VIII. Authorized Official

Name: DR. KRISTIN L. BOUDREAUX
Title or Position: OWNER
Credential: D.C.
Phone: 337-261-2669