Healthcare Provider Details

I. General information

NPI: 1063555662
Provider Name (Legal Business Name): GERRY G PROVANCE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 CLEARVIEW PKWY
METAIRIE LA
70001-2404
US

IV. Provider business mailing address

2007 CLEARVIEW PKWY
METAIRIE LA
70001-2404
US

V. Phone/Fax

Practice location:
  • Phone: 504-456-9296
  • Fax: 504-456-9799
Mailing address:
  • Phone: 504-456-9296
  • Fax: 504-456-9799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number414
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: