Provider Demographics
NPI:1215242045
Name:PATRICK W. BOURQUE, D.C., INC
Entity type:Organization
Organization Name:PATRICK W. BOURQUE, D.C., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURQUE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:225-744-3902
Mailing Address - Street 1:17487 OLD JEFFERSON HWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4043
Mailing Address - Country:US
Mailing Address - Phone:225-744-3902
Mailing Address - Fax:
Practice Address - Street 1:17487 OLD JEFFERSON HWY
Practice Address - Street 2:SUITE D
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-4043
Practice Address - Country:US
Practice Address - Phone:225-744-3902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1108111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAU66648Medicare UPIN