Provider Demographics
NPI:1285936914
Name:BACK PAIN CHIROPRACTIC
Entity type:Organization
Organization Name:BACK PAIN CHIROPRACTIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:BALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-746-4445
Mailing Address - Street 1:2170 AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3106
Mailing Address - Country:US
Mailing Address - Phone:318-746-4445
Mailing Address - Fax:318-746-0353
Practice Address - Street 1:2170 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3106
Practice Address - Country:US
Practice Address - Phone:318-746-4445
Practice Address - Fax:318-746-0353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA768111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2918AOtherBLUE CROSS BLUE SHIELD
LA59401Medicare UPIN