Healthcare Provider Details

I. General information

NPI: 1558289066
Provider Name (Legal Business Name): NICHOLAS SONG DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 FONTAINBLEAU DR STE D1
MANDEVILLE LA
70471-6519
US

IV. Provider business mailing address

102 FONTAINBLEAU DR STE D1
MANDEVILLE LA
70471-6519
US

V. Phone/Fax

Practice location:
  • Phone: 985-400-5300
  • Fax: 985-400-5301
Mailing address:
  • Phone: 985-400-5300
  • Fax: 985-400-5301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2088
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: