1972544344 NPI number — MID-SOUTH CHIROPRACTIC, LLC

Table of content: (NPI 1972544344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972544344 NPI number — MID-SOUTH CHIROPRACTIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-SOUTH CHIROPRACTIC, 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:
1972544344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6253 GOODMAN ROAD
Provider Second Line Business Mailing Address:
SUITE A & B
Provider Business Mailing Address City Name:
OLIVE BRANCH
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38654-9391
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-890-0012
Provider Business Mailing Address Fax Number:
662-890-0522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6253 GOODMAN ROAD
Provider Second Line Business Practice Location Address:
SUITE A & B
Provider Business Practice Location Address City Name:
OLIVE BRANCH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38654-9391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-890-0012
Provider Business Practice Location Address Fax Number:
662-890-0522
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
LAWTON
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
662-890-0012

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1518 , 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)

  • Identifier: 701292 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7696844 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 409574769 . This is a "BLUE CROSS BLUE SHIELD MS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 0111474 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 701292 . This is a "GOLDEN RULE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 701292 . This is a "GE WELLNESS PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4131570 . This is a "BLUE CROSS BLUE SHIELD TN" identifier . This identifiers is of the category "OTHER".




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