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General NPI Number Information
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NPI Number | 1891122594
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Entity Type | Organization
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Legal Business Name | ULTIMATE PERFORMANCE CHIROPRACTIC & REHAB, LLC
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Dates
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Enumeration Date | 09/26/2013
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Last Update Date | 12/04/2014
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Provider Practice Location Address
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Address Line | 646 W. MCNEESE STREET
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City | LAKE CHARLES
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State | LA
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Zip | 70605
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Country | US
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Telephone | 337-421-0010
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Fax | 337-421-0032
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Provider Business Mailing Address
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Address Line | 646 W. MCNEESE STREET
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City | LAKE CHARLES
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State | LA
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Zip | 70605
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Country | US
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Telephone | 337-421-0010
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Fax | 337-421-0032
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | KYLE A DAIGLE
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Credential | DC
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Telephone | 337-421-0010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 1658
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License Number State | LA
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