Provider Demographics
NPI:1720062177
Name:DEROUEN, SCOTT P (DC)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:P
Last Name:DEROUEN
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 1:1210 E MCNEESE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-4756
Mailing Address - Country:US
Mailing Address - Phone:337-502-5303
Mailing Address - Fax:337-479-2391
Practice Address - Street 1:1210 E MCNEESE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4756
Practice Address - Country:US
Practice Address - Phone:337-502-5303
Practice Address - Fax:337-479-2391
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1050111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA350052044OtherRAILROAD MEDICARE
U58966Medicare UPIN
5T852Medicare ID - Type Unspecified