Provider Demographics
NPI:1538609193
Name:PELICAN STATE CHIROPRACTIC LLC
Entity type:Organization
Organization Name:PELICAN STATE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:VIALIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-738-9955
Mailing Address - Street 1:PO BOX 2537
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71207-2537
Mailing Address - Country:US
Mailing Address - Phone:318-237-6396
Mailing Address - Fax:
Practice Address - Street 1:805 PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-2631
Practice Address - Country:US
Practice Address - Phone:318-237-6396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA540111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty