Provider Demographics
NPI:1477759207
Name:WYNNE CHIROPRACTIC CLINIC, INC
Entity Type:Organization
Organization Name:WYNNE CHIROPRACTIC CLINIC, INC
Other - Org Name:BUTLER CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:870-523-5257
Mailing Address - Street 1:2301 HIGHWAY 367 N
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-2325
Mailing Address - Country:US
Mailing Address - Phone:870-523-5257
Mailing Address - Fax:870-523-5263
Practice Address - Street 1:2301 HIGHWAY 367 N
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-2325
Practice Address - Country:US
Practice Address - Phone:870-523-5257
Practice Address - Fax:870-523-5263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1155111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136123718Medicaid
AR136123718Medicaid
AR5B627Medicare ID - Type UnspecifiedCLINIC PROVIDER NUMBER