Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 656 | LA |
N | 111NN1001X | Nutrition | 656 | LA |
NPI | 1164434478 |
---|---|
Provider Name | Dr. Bryan John Dufrene |
First Address | Raceland, LA 70394-3141 |
Second Address | Raceland, LA 70394-3141 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2006 |
Last Update Date | 02/11/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2183A | PROVIDER (01) | LA |
T-20096 | (02) | LA |