Healthcare Provider Details

I. General information

NPI: 1659569119
Provider Name (Legal Business Name): MOSS BLUFF CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 TAHOE DR
LAKE CHARLES LA
70611-5109
US

IV. Provider business mailing address

PO BOX 12571
LAKE CHARLES LA
70612-2571
US

V. Phone/Fax

Practice location:
  • Phone: 337-855-6306
  • Fax: 337-855-7012
Mailing address:
  • Phone: 337-855-6306
  • Fax: 337-855-7012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: CHAD RICHARD
Title or Position: OWNER
Credential: D.C.
Phone: 337-855-6306