1053513796 NPI number — FAMILY CHIROPRACTIC CENTER

Table of content: (NPI 1053513796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053513796 NPI number — FAMILY CHIROPRACTIC CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY CHIROPRACTIC 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:
1053513796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 N COLLEGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL DORADO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71730-5402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-862-9770
Provider Business Mailing Address Fax Number:
870-862-2127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 N COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL DORADO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71730-5402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-862-9770
Provider Business Practice Location Address Fax Number:
870-862-2127
Provider Enumeration Date:
06/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
870-862-9770

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1087 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 119330718 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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