Provider Demographics
NPI:1063555662
Name:PROVANCE, GERRY G (DC)
Entity type:Individual
Prefix:
First Name:GERRY
Middle Name:G
Last Name:PROVANCE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 CLEARVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-2404
Mailing Address - Country:US
Mailing Address - Phone:504-456-9296
Mailing Address - Fax:504-456-9799
Practice Address - Street 1:2007 CLEARVIEW PKWY
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-2404
Practice Address - Country:US
Practice Address - Phone:504-456-9296
Practice Address - Fax:504-456-9799
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA414111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC8327OtherBLUE CROSS ID
LA1951340Medicaid
LAT19890Medicare UPIN
LA1951340Medicaid