Healthcare Provider Details

I. General information

NPI: 1104939271
Provider Name (Legal Business Name): PATRICK W. BOURQUE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 05/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17487 OLD JEFFERSON HWY SUITE D
PRAIRIEVILLE LA
70769-4043
US

IV. Provider business mailing address

17487 OLD JEFFERSON HWY SUITE D
PRAIRIEVILLE LA
70769-4043
US

V. Phone/Fax

Practice location:
  • Phone: 225-744-3902
  • Fax: 225-744-3952
Mailing address:
  • Phone: 225-744-3902
  • Fax: 225-744-3952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1108
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number4158
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: