Healthcare Provider Details

I. General information

NPI: 1720174170
Provider Name (Legal Business Name): CHAD RICHARD D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MOSS BLUFF CHIROPRACTIC CLINIC 119 TAHOE DR
LAKE CHARLES LA
70611-5109
US

IV. Provider business mailing address

119 TAHOE DR PO BOX 12571
LAKE CHARLES LA
70611-5109
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 Number954
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: