Provider Demographics
NPI:1689915183
Name:INNATE POTENTIAL CHIROPRACTIC LLC
Entity type:Organization
Organization Name:INNATE POTENTIAL CHIROPRACTIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONNY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:985-900-4210
Mailing Address - Street 1:60154 NINA DR
Mailing Address - Street 2:
Mailing Address - City:LACOMBE
Mailing Address - State:LA
Mailing Address - Zip Code:70445-3938
Mailing Address - Country:US
Mailing Address - Phone:985-900-4210
Mailing Address - Fax:504-335-0740
Practice Address - Street 1:2163 GAUSE BLVD W STE 4
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70460-4132
Practice Address - Country:US
Practice Address - Phone:985-250-4465
Practice Address - Fax:504-335-0740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1661111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1891048344OtherINDIVIDUAL NPI