Provider Demographics
NPI:1992912380
Name:EASTGATE CHIROPRACTIC CLINIC, INC
Entity type:Organization
Organization Name:EASTGATE CHIROPRACTIC CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:V
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-222-6297
Mailing Address - Street 1:1520 N HEARNE AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-7155
Mailing Address - Country:US
Mailing Address - Phone:318-222-6298
Mailing Address - Fax:318-222-6299
Practice Address - Street 1:1520 N HEARNE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-7155
Practice Address - Country:US
Practice Address - Phone:318-222-6298
Practice Address - Fax:318-222-6299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA973111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty