Provider Demographics
NPI:1457663270
Name:T. H. GREEN CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:T. H. GREEN CHIROPRACTIC, LLC
Other - Org Name:GREEN CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-522-9395
Mailing Address - Street 1:1134 W. MAPLEWOOD ST.
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-4763
Mailing Address - Country:US
Mailing Address - Phone:417-522-9395
Mailing Address - Fax:
Practice Address - Street 1:1713 US HIGHWAY 160 WEST
Practice Address - Street 2:SOUTH RIDGE PLAZA, SUITE 215
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-7669
Practice Address - Country:US
Practice Address - Phone:417-257-1184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005235111N00000X
171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO756208302Medicaid
MO756208302Medicaid