1457663270 NPI number — T. H. GREEN CHIROPRACTIC, LLC

Table of content: (NPI 1457663270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457663270 NPI number — T. H. GREEN CHIROPRACTIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
T. H. GREEN CHIROPRACTIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GREEN CHIROPRACTIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457663270
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1134 W. MAPLEWOOD ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65807-4763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-522-9395
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1713 US HIGHWAY 160 WEST
Provider Second Line Business Practice Location Address:
SOUTH RIDGE PLAZA, SUITE 215
Provider Business Practice Location Address City Name:
WEST PLAINS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65775-7669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-257-1184
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/09/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
HOWARD
Authorized Official Title or Position:
DOCTOR OF CHIROPRACTIC
Authorized Official Telephone Number:
417-522-9395

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  005235 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 756208302 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".