1184103376 NPI number — PERRY COUNTY CHIROPRACTIC, LLC

Table of content: (NPI 1184103376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184103376 NPI number — PERRY COUNTY CHIROPRACTIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERRY COUNTY 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:
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:
1184103376
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAUMELLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72113-7407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-851-6685
Provider Business Mailing Address Fax Number:
501-851-6495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 HOUSTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PERRYVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72126-9451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-889-5555
Provider Business Practice Location Address Fax Number:
501-851-6495
Provider Enumeration Date:
08/09/2018

Additional Information

Authorized Official

Authorized Official Last Name:
FOWLER
Authorized Official First Name:
TRAY
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
CHIROPRACTOR/PARTNER
Authorized Official Telephone Number:
214-632-9022

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  16033 , 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)





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