1700416450 NPI number — WEST KENTUCKY CHIROPRACTIC AND PERFORMANCE CENTER

Table of content: LYNN PATRICIA ANDERSON DEMOTT LCSW (NPI 1164487195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700416450 NPI number — WEST KENTUCKY CHIROPRACTIC AND PERFORMANCE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST KENTUCKY CHIROPRACTIC AND PERFORMANCE CENTER
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:
1700416450
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 LONGACRE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42025-7878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110B E 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42025-1118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-703-7074
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2020

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
TANNER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/OPERATOR/CHIROPRACTOR
Authorized Official Telephone Number:
270-703-7074

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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