Provider Demographics
NPI:1235319708
Name:NORTHWEST CHIROPRACTIC CLINIC, LLC
Entity Type:Organization
Organization Name:NORTHWEST CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:660-582-8099
Mailing Address - Street 1:206 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2229
Mailing Address - Country:US
Mailing Address - Phone:660-582-8099
Mailing Address - Fax:660-582-5161
Practice Address - Street 1:206 W 2ND ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2229
Practice Address - Country:US
Practice Address - Phone:660-582-8099
Practice Address - Fax:660-582-5161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOK302912Medicare UPIN
MOK308199Medicare UPIN