Provider Demographics
NPI:1356675664
Name:MITCHELL CLINIC LLC
Entity Type:Organization
Organization Name:MITCHELL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERRY
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:573-265-0310
Mailing Address - Street 1:120 S JEFFERSON ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAINT JAMES
Mailing Address - State:MO
Mailing Address - Zip Code:65559-1365
Mailing Address - Country:US
Mailing Address - Phone:573-265-0310
Mailing Address - Fax:
Practice Address - Street 1:120 S JEFFERSON ST
Practice Address - Street 2:SUITE 105
Practice Address - City:SAINT JAMES
Practice Address - State:MO
Practice Address - Zip Code:65559-1365
Practice Address - Country:US
Practice Address - Phone:573-265-0310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009026117111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty