1598081895 NPI number — MAYWOOD CHIROPRACTIC CLINIC

Table of content: (NPI 1598081895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598081895 NPI number — MAYWOOD CHIROPRACTIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAYWOOD CHIROPRACTIC CLINIC
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:
Provider Other Organization Name Type Code:
6
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:
1598081895
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 LAKELAND SQUARE EXT
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-7620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-932-3855
Provider Business Mailing Address Fax Number:
601-932-6557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 LAKELAND SQUARE EXT
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-7620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-932-3855
Provider Business Practice Location Address Fax Number:
601-932-6557
Provider Enumeration Date:
04/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MCLENDON
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
TANNER
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
601-932-3855

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  124 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00115753 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 302G351184 . This is a "MEDICARE P-TAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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