1326025867 NPI number — CROCKETT CHIROPRACTIC, PC

Table of content: (NPI 1326025867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326025867 NPI number — CROCKETT CHIROPRACTIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROCKETT CHIROPRACTIC, PC
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:
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:
1326025867
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
733 W KEARNEY 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:
65803-1229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-831-7575
Provider Business Mailing Address Fax Number:
417-831-7632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
733 W KEARNEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65803-1229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-831-7575
Provider Business Practice Location Address Fax Number:
417-831-7632
Provider Enumeration Date:
12/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CROCKETT
Authorized Official First Name:
JASON
Authorized Official Middle Name:
MITCHELL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
417-831-7575

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2001006863 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7825256 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 466725 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 472348 . This is a "BLUE CHOICE OF KANSAS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 143164 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1921532 . This is a "FIRST HEALTH & CCN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4400576 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 9168688 . This is a "PRIVATE HEALTHCARE SYSTEM" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 755773900 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: DE9027 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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