1639252703 NPI number — ANDOVER CHIROPRACTIC CENTER, INC.

Table of content: (NPI 1639252703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639252703 NPI number — ANDOVER CHIROPRACTIC CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDOVER CHIROPRACTIC CENTER, 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:
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:
1639252703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 593
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDOVER
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67002-0593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-733-5454
Provider Business Mailing Address Fax Number:
316-733-5404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 W CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
ANDOVER
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67002-9616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-733-5454
Provider Business Practice Location Address Fax Number:
316-733-5404
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POE
Authorized Official First Name:
RODNEY
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
316-733-5454

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  01-03532 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3013 . This is a "PHS - PROVIDER #" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 660187 . This is a "BC/BS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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