Provider Demographics
NPI:1366590648
Name:BROUSSARD CHIROPRACTIC CENTER, INC
Entity type:Organization
Organization Name:BROUSSARD CHIROPRACTIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LATRESIA
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:225-618-8016
Mailing Address - Street 1:331 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:NEW ROADS
Mailing Address - State:LA
Mailing Address - Zip Code:70760-2622
Mailing Address - Country:US
Mailing Address - Phone:225-618-8016
Mailing Address - Fax:225-618-8028
Practice Address - Street 1:331 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:NEW ROADS
Practice Address - State:LA
Practice Address - Zip Code:70760-2622
Practice Address - Country:US
Practice Address - Phone:225-618-8016
Practice Address - Fax:225-618-8028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1307111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1509060Medicaid
LA6399070001Medicare NSC
LA1509060Medicaid
LA4C668CT63Medicare ID - Type Unspecified