MEDICARE: MAYFIELD CHRIOPRACTIC WEST INC

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	1352	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4050634820	OTHER	LA	BLUE CROSS BLUE SHIELD LA

General Provider Information

NPI Number	:	1609904861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAYFIELD CHRIOPRACTIC WEST INC

Provider Business Mailing Address
First Line	:	PO BOX 2274
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71294-2274
Country	:	US
Telephone Number	:	318-396-5558
Fax Number	:	318-396-9119

Provider Business Practice Location Address
First Line	:	4900 CYPRESS ST
Second Line	:	SIUTE 13
City	:	WEST MONROE
State	:	LA
Zip	:	71291-7670
Country	:	US
Telephone Number	:	318-396-5558
Fax Number	:	318-396-9119

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHARLES WILLIAM MAYFIELD
Credential	:	D.C.
Telephone Number	:	318-396-5558

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/01/2011

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Directions to “MAYFIELD CHRIOPRACTIC WEST INC ” Practice Location

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