1720214471 NPI number — GERMANTOWN CHIROPRACTIC, PSC

Table of content: BENNETT GRAHAM ODEN MD (NPI 1427665157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720214471 NPI number — GERMANTOWN CHIROPRACTIC, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERMANTOWN CHIROPRACTIC, PSC
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:
1720214471
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 MILTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40217-1259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-637-7754
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 MILTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40217-1259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-637-7754
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MURROW
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CHIROPRACTOR/OWNER
Authorized Official Telephone Number:
502-637-7754

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  5106 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5597 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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