Provider Demographics
NPI:1225237837
Name:POWELL CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:POWELL CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RODGER
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:660-744-2032
Mailing Address - Street 1:604 S MAIN ST # 274
Mailing Address - Street 2:
Mailing Address - City:ROCK PORT
Mailing Address - State:MO
Mailing Address - Zip Code:64482-1448
Mailing Address - Country:US
Mailing Address - Phone:660-744-2032
Mailing Address - Fax:660-744-2062
Practice Address - Street 1:604 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCK PORT
Practice Address - State:MO
Practice Address - Zip Code:64482-1448
Practice Address - Country:US
Practice Address - Phone:660-744-2032
Practice Address - Fax:660-744-2062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO3551111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C590000Medicare PIN