Provider Demographics
NPI:1003023631
Name:POWELL, HAYDN BURK JR
Entity Type:Individual
Prefix:
First Name:HAYDN
Middle Name:BURK
Last Name:POWELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 HWY 32 WEST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560
Mailing Address - Country:US
Mailing Address - Phone:573-729-3542
Mailing Address - Fax:
Practice Address - Street 1:803 W HIGHWAY 32
Practice Address - Street 2:SUITE B
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-2576
Practice Address - Country:US
Practice Address - Phone:573-729-3542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003881111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000030342Medicare ID - Type Unspecified