Provider Demographics
NPI:1457484545
Name:PETAL CHIROPRACTIC CLINIC, INC.
Entity Type:Organization
Organization Name:PETAL CHIROPRACTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:601-545-1481
Mailing Address - Street 1:130 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2345
Mailing Address - Country:US
Mailing Address - Phone:601-545-1481
Mailing Address - Fax:601-545-1449
Practice Address - Street 1:130 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2345
Practice Address - Country:US
Practice Address - Phone:601-545-1481
Practice Address - Fax:601-545-1449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty