1811249667 NPI number — CHIROPRACTIC OF THE SOUTH, PLLC

Table of content: (NPI 1811249667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811249667 NPI number — CHIROPRACTIC OF THE SOUTH, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROPRACTIC OF THE SOUTH, PLLC
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:
1811249667
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1029 HIGHWAY 51
Provider Second Line Business Mailing Address:
STE. F2
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39110-6603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-605-0903
Provider Business Mailing Address Fax Number:
601-510-9415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1029 HIGHWAY 51
Provider Second Line Business Practice Location Address:
STE. F2
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39110-6603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-605-0903
Provider Business Practice Location Address Fax Number:
601-510-9415
Provider Enumeration Date:
10/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
FORTINBERRY
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
SLOANE
Authorized Official Title or Position:
DR./OWNER
Authorized Official Telephone Number:
601-605-0903

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1189 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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