Provider Demographics
NPI:1871767186
Name:MANDEVILLE CHIROPRACTIC
Entity type:Organization
Organization Name:MANDEVILLE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:DERBES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-626-7795
Mailing Address - Street 1:235 W FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-3056
Mailing Address - Country:US
Mailing Address - Phone:985-626-7795
Mailing Address - Fax:
Practice Address - Street 1:235 W FLORIDA ST
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-3056
Practice Address - Country:US
Practice Address - Phone:985-626-7795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPINAL REHABILITATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-17
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1080305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C682D377Medicare PIN