Provider Demographics
NPI:1114042249
Name:MELANIE D GODFREY DC LLC
Entity type:Organization
Organization Name:MELANIE D GODFREY DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-281-3911
Mailing Address - Street 1:634 EAST JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-4619
Mailing Address - Country:US
Mailing Address - Phone:318-281-3911
Mailing Address - Fax:318-281-3690
Practice Address - Street 1:634 EAST JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4619
Practice Address - Country:US
Practice Address - Phone:318-281-3911
Practice Address - Fax:318-281-3690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1396111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4396585240OtherBLUE CROSS
LA1712485Medicaid
AR83816OtherBLUE CROSS
LA1712485Medicaid