Healthcare Provider Details

I. General information

NPI: 1629111661
Provider Name (Legal Business Name): 11TH STREET CHIROPRACTIC CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N 11TH ST
BEAUMONT TX
77702-2212
US

IV. Provider business mailing address

1919 VETERANS BOULEVARD SUITE 200
KENNER LA
70062
US

V. Phone/Fax

Practice location:
  • Phone: 409-838-0909
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: BUFFIE L ROME VI
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 504-467-0302