1659562148 NPI number — CUSTOM CHIROPRACTIC CENTER LLC

Table of content: (NPI 1659562148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659562148 NPI number — CUSTOM CHIROPRACTIC CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUSTOM CHIROPRACTIC CENTER 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:
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:
1659562148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6220 ANTIOCH RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SHAWNEE MISSION
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66202-2866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-722-1113
Provider Business Mailing Address Fax Number:
913-722-2677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6220 ANTIOCH RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SHAWNEE MISSION
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66202-2866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-722-1113
Provider Business Practice Location Address Fax Number:
913-722-2677
Provider Enumeration Date:
08/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RUDD
Authorized Official First Name:
ARVIL
Authorized Official Middle Name:
LONNIE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
913-722-1113

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  01-04887 , 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: 33911023 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00220339 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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