Provider Demographics
NPI:1407129992
Name:ELEVATION CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:ELEVATION CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:UCHTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:573-450-8088
Mailing Address - Street 1:1812 CARONDALET DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2285
Mailing Address - Country:US
Mailing Address - Phone:573-450-8088
Mailing Address - Fax:
Practice Address - Street 1:1812 CARONDALET DR
Practice Address - Street 2:SUITE 102
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2285
Practice Address - Country:US
Practice Address - Phone:573-450-8088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011005972111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2011005972OtherMO LICENSE
1356531420OtherINDIVIDUAL NPI
MO2011005972OtherMO LICENSE