Provider Demographics
NPI:1326025867
Name:CROCKETT CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:CROCKETT CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-831-7575
Mailing Address - Street 1:733 W KEARNEY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-1229
Mailing Address - Country:US
Mailing Address - Phone:417-831-7575
Mailing Address - Fax:417-831-7632
Practice Address - Street 1:733 W KEARNEY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-1229
Practice Address - Country:US
Practice Address - Phone:417-831-7575
Practice Address - Fax:417-831-7632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001006863111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
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MO1921532OtherFIRST HEALTH & CCN
MO4400576OtherUNITED HEALTHCARE
MO9168688OtherPRIVATE HEALTHCARE SYSTEM
MO755773900Medicaid
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MODE9027OtherRAILROAD MEDICARE