Provider Demographics
NPI:1023367471
Name:MIDWEST CHIROPRACTIC CENTER LLC
Entity Type:Organization
Organization Name:MIDWEST CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:G
Authorized Official - Last Name:HEABERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:573-426-4300
Mailing Address - Street 1:2001 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-9687
Mailing Address - Country:US
Mailing Address - Phone:573-426-4300
Mailing Address - Fax:573-426-2009
Practice Address - Street 1:1081 E 18TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2448
Practice Address - Country:US
Practice Address - Phone:573-426-4300
Practice Address - Fax:573-426-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011003626111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty