Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 1179 | MS |
N | 111NN1001X | Nutrition | 1179 | MS |
N | 111NR0400X | Rehabilitation Chiropractor | 1179 | MS |
N | 111NS0005X | Chiropractic Sports Physician | 1179 | MS |
NPI | 1235418807 |
---|---|
Provider Name | Dr. John Mackertich Bamban |
First Address | Diberville, MS 39540-5424 |
Second Address | Diberville, MS 39540-2725 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2011 |
Last Update Date | 19/10/2020 |