Provider Demographics
NPI:1396047981
Name:MAYFIELD-BACON AUTO ACCIDENT & INJURY CLINIC LLC
Entity type:Organization
Organization Name:MAYFIELD-BACON AUTO ACCIDENT & INJURY CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-828-1517
Mailing Address - Street 1:2219 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2128
Mailing Address - Country:US
Mailing Address - Phone:318-828-1517
Mailing Address - Fax:318-855-1685
Practice Address - Street 1:2219 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2128
Practice Address - Country:US
Practice Address - Phone:318-855-1517
Practice Address - Fax:318-828-1685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1067111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty