Healthcare Provider Details

I. General information

NPI: 1023341864
Provider Name (Legal Business Name): CHARLES KIRCHEM IV DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12371 HIGHWAY 90 SUITE D
LULING LA
70070-5114
US

IV. Provider business mailing address

12371 HWY. 90 SUITE D
LULING LA
70070
US

V. Phone/Fax

Practice location:
  • Phone: 985-331-1001
  • Fax: 985-331-1005
Mailing address:
  • Phone: 985-331-1001
  • Fax: 985-331-1005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number07655
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: