Provider Demographics
NPI:1043583446
Name:CLASSIC CHIROPRACTIC CARE CLINIC, LLC
Entity type:Organization
Organization Name:CLASSIC CHIROPRACTIC CARE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:3374-889-1111
Mailing Address - Street 1:910 8TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-4832
Mailing Address - Country:US
Mailing Address - Phone:337-488-9111
Mailing Address - Fax:337-439-1526
Practice Address - Street 1:910 8TH AVENUE
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-4832
Practice Address - Country:US
Practice Address - Phone:337-488-9111
Practice Address - Fax:337-439-1526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1619111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty