=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457584773
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHIROPRACTIC WELLNESS CENTER, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2009
-----------------------------------------------------
Last Update Date | 09/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7068 READ BLVD
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70127-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-248-5560
-----------------------------------------------------
Fax | 504-248-5599
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7068 READ BLVD
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70127-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-248-5560
-----------------------------------------------------
Fax | 504-248-5599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | LINDA PHAM
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 504-248-5560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1402
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------