Healthcare Provider Details

I. General information

NPI: 1669850152
Provider Name (Legal Business Name): PROVANCE CHIROPRACTIC SPORTS AND WELLNESS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2015
Last Update Date: 05/15/2015
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:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1508
License Number StateLA

VIII. Authorized Official

Name: JAMES E RIZER
Title or Position: CO-OWNER
Credential: DC
Phone: 504-456-9296