Provider Demographics
NPI:1144731399
Name:GULF COAST SPORT AND SPINE
Entity type:Organization
Organization Name:GULF COAST SPORT AND SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBOURGEOIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:504-372-4062
Mailing Address - Street 1:3941 HOUMA BLVD STE 2A
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2920
Mailing Address - Country:US
Mailing Address - Phone:504-372-4062
Mailing Address - Fax:
Practice Address - Street 1:3941 HOUMA BLVD STE 2A
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2920
Practice Address - Country:US
Practice Address - Phone:504-372-4062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty