Provider Demographics
NPI:1902063233
Name:DRS FLYNN MANCEAUX A PROFESSIONAL CHIROPRACTIC AND PHYSICAL THERAPY CO
Entity Type:Organization
Organization Name:DRS FLYNN MANCEAUX A PROFESSIONAL CHIROPRACTIC AND PHYSICAL THERAPY CO
Other - Org Name:FLYNN MANCEAUX ARCEMENT PIZZOLATO A PROFESSIONAL CHIROPRACTIC AND PHYS
Other - Org Type:Other Name
Authorized Official - Title/Position:CO-OWNER, CORP. PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MANCEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-868-3136
Mailing Address - Street 1:6902 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-2455
Mailing Address - Country:US
Mailing Address - Phone:985-868-3136
Mailing Address - Fax:985-868-4040
Practice Address - Street 1:6902 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2455
Practice Address - Country:US
Practice Address - Phone:985-868-3136
Practice Address - Fax:985-868-4040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA638111N00000X
LA985111N00000X
LA1112111N00000X
LA1279111N00000X
LA277111N00000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAU20090Medicare UPIN
LA4C220Medicare PIN
LA5X334Medicare PIN
LAU46784Medicare UPIN
LAU90019Medicare UPIN
LA59463Medicare PIN
LAU67208Medicare UPIN
LA5T568Medicare PIN
LA59462Medicare PIN
LAU20091Medicare UPIN