Provider Demographics
NPI:1184818650
Name:BALLARD CHIROPRACTIC
Entity Type:Organization
Organization Name:BALLARD CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:MACK
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:II
Authorized Official - Credentials:DC, FICC
Authorized Official - Phone:662-226-4388
Mailing Address - Street 1:PO BOX 1291
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38902-1291
Mailing Address - Country:US
Mailing Address - Phone:662-226-4388
Mailing Address - Fax:662-226-4538
Practice Address - Street 1:1301I SUNSET DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4003
Practice Address - Country:US
Practice Address - Phone:662-226-4388
Practice Address - Fax:662-226-4538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0021111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00503669Medicaid
MS00115516Medicaid
MS424480961AOtherBLUE CROSS
MSC00653Medicare PIN
MST20752Medicare UPIN