1821143009 NPI number — MAGNA CHIRO MED, LLC

Table of content: (NPI 1821143009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821143009 NPI number — MAGNA CHIRO MED, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNA CHIRO MED, 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:
6
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:
1821143009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2424 AIRWAY DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
BOWLING GREEN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42103-7125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-746-9400
Provider Business Mailing Address Fax Number:
270-746-0240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2424 AIRWAY DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BOWLING GREEN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42103-7125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-746-9400
Provider Business Practice Location Address Fax Number:
270-746-0240
Provider Enumeration Date:
01/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
KELLI
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
270-746-9400

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4950 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 85003317 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1285629154 . This is a "NPI" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 85003762 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396723755 . This is a "NPI" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1821143009 . This is a "CLINIC NPI" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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