1770663239 NPI number — LOOKOUT VALLEY CHIROPRACTIC

Table of content: (NPI 1770663239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770663239 NPI number — LOOKOUT VALLEY CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOOKOUT VALLEY CHIROPRACTIC
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:
1770663239
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3536 CUMMINGS HWY
Provider Second Line Business Mailing Address:
STE120
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37419-2435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-825-5252
Provider Business Mailing Address Fax Number:
423-825-1228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3536 CUMMINGS HWY
Provider Second Line Business Practice Location Address:
STE120
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37419-2435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-825-5252
Provider Business Practice Location Address Fax Number:
423-825-1228
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KJOS
Authorized Official First Name:
NEIL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
423-825-5252

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  1430 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 350052346 . This is a "RAILROAD MC PALMETTO GBA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 5011638 . This is a "AETNA PIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000933226A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3069538 . This is a "BLUE CROSS PIN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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