Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 768 | LA |
NPI | 1013020049 |
---|---|
Provider Name | Louie T Ballis |
First Address | Bossier City, LA 71111-3106 |
Second Address | Bossier City, LA 71111 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/08/2006 |
Last Update Date | 17/02/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2918A | BLUE CROSS BLUE SHIELD (01) | LA |