=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497369250
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANIMUS CHIROPRACTIC AND ALTERNATIVE MEDICINE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2020
-----------------------------------------------------
Last Update Date | 01/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 N CAUSEWAY BLVD STE 2
-----------------------------------------------------
City | MANDEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70471-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-778-2695
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1120 N CAUSEWAY BLVD STE 2
-----------------------------------------------------
City | MANDEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70471-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-778-2695
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | DR. AUSTIN FONTENOT
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 985-705-5392
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111NN1001X
-----------------------------------------------------
Taxonomy Name | Nutrition Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------