Provider Demographics
NPI:1083891428
Name:HEARTLAND FAMILY CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:HEARTLAND FAMILY CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:FULKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:270-234-8880
Mailing Address - Street 1:1606 N DIXIE HWY
Mailing Address - Street 2:STE 111
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-5565
Mailing Address - Country:US
Mailing Address - Phone:270-234-8880
Mailing Address - Fax:270-234-1343
Practice Address - Street 1:1606 N DIXIE HWY STE 111
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-5572
Practice Address - Country:US
Practice Address - Phone:270-234-8880
Practice Address - Fax:270-234-1343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4563111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85003002Medicaid
KY85003002Medicaid
KY00687Medicare PIN