1356411276 NPI number — TWIN LAKES CHIROPRACTIC CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356411276 NPI number — TWIN LAKES CHIROPRACTIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWIN LAKES 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:
1356411276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 148
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEVIEW
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72642-0148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-431-8900
Provider Business Mailing Address Fax Number:
870-431-8810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4898 HIGHWAY 178 WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEVIEW
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-431-8900
Provider Business Practice Location Address Fax Number:
870-431-8810
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
UNGERANK
Authorized Official First Name:
MARK
Authorized Official Middle Name:
LUDEAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
870-431-8900

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  904 , 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: 101032718 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: DC2383 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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