Provider Demographics
NPI:1033302682
Name:FRACK, LARRY DALE (DC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DALE
Last Name:FRACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:WEBB CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64870-2901
Mailing Address - Country:US
Mailing Address - Phone:417-673-5556
Mailing Address - Fax:417-673-5088
Practice Address - Street 1:1506 S MADISON ST
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-2901
Practice Address - Country:US
Practice Address - Phone:417-673-5556
Practice Address - Fax:417-673-5088
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO6356111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU13892Medicare UPIN