Healthcare Provider Details

I. General information

NPI: 1679963177
Provider Name (Legal Business Name): BG4G LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 03/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 VETERANS BLVD SUITE 130
METAIRIE LA
70005-3027
US

IV. Provider business mailing address

23482 JUDITH ST
MANDEVILLE LA
70448-8430
US

V. Phone/Fax

Practice location:
  • Phone: 504-321-0411
  • Fax: 504-321-0412
Mailing address:
  • Phone: 504-321-0411
  • Fax: 504-321-0412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1518
License Number StateLA

VIII. Authorized Official

Name: DR. BENJAMIN J DICHIARA
Title or Position: OWNER
Credential: D.C.
Phone: 504-232-4562