MEDICARE: RYAN J VIDRINE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1326712308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RYAN J VIDRINE LLC

Provider Business Mailing Address
First Line	:	326 SETTLERS TRACE BLVD # 201-C
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-6091
Country	:	US
Telephone Number	:	337-412-8538
Fax Number	:

Provider Business Practice Location Address
First Line	:	326 SETTLERS TRACE BLVD # 201-C
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-6091
Country	:	US
Telephone Number	:	337-412-8538
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RYAN J VIDRINE
Credential	:	DC
Telephone Number	:	337-412-8538

Provider Enumeration Date	:	08/04/2021
Last Update Date	:	08/04/2021

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