1477759207 NPI number — WYNNE CHIROPRACTIC CLINIC, INC

Table of content: (NPI 1477759207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477759207 NPI number — WYNNE CHIROPRACTIC CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYNNE CHIROPRACTIC CLINIC, INC
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:
1477759207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 HIGHWAY 367 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72112-2325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-523-5257
Provider Business Mailing Address Fax Number:
870-523-5263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 HIGHWAY 367 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72112-2325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-523-5257
Provider Business Practice Location Address Fax Number:
870-523-5263
Provider Enumeration Date:
06/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BUTLER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
870-523-5257

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1155 , 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: 136123718 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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