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General NPI Number Information
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NPI Number | 1235418807
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Entity Type | Individual
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Provider Name | JOHN MACKERTICH BAMBAN DC
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Gender | Male
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Dates
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Enumeration Date | 08/12/2011
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Last Update Date | 10/19/2020
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Provider Practice Location Address
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Address Line | 11516 LAMEY BRIDGE RD STE E
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City | DIBERVILLE
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State | MS
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Zip | 39540-2725
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Country | US
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Telephone | 228-207-6427
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Fax | 228-207-6428
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Provider Business Mailing Address
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Address Line | 10028B FOURNIER AVE
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City | DIBERVILLE
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State | MS
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Zip | 39540-5424
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Country | US
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Telephone | 770-733-5205
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NN1001X
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Taxonomy Name | Nutrition Chiropractor
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License Number | 1179
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | 1179
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License Number State | MS
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Taxonomy #3
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 1179
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License Number State | MS
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Taxonomy #4
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 1179
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License Number State | MS
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