Provider Demographics
NPI:1073552014
Name:APPALUCKY MISSION OF INTEGRATED HEALTH INC
Entity Type:Organization
Organization Name:APPALUCKY MISSION OF INTEGRATED HEALTH INC
Other - Org Name:APPALUCKY MISSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MASJA
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:606-666-5226
Mailing Address - Street 1:PO BOX 474
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-0474
Mailing Address - Country:US
Mailing Address - Phone:606-666-5226
Mailing Address - Fax:
Practice Address - Street 1:330 BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-1036
Practice Address - Country:US
Practice Address - Phone:606-666-5226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4355111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U66384Medicare UPIN
KY6077401Medicare ID - Type Unspecified