Provider Demographics
NPI:1477820967
Name:MT VERNON CHIROPRACTIC CLINIC PLLC
Entity Type:Organization
Organization Name:MT VERNON CHIROPRACTIC CLINIC PLLC
Other - Org Name:MT VERNON CHIROPRACTIC CLININC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER & PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:MANNIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-588-2237
Mailing Address - Street 1:1933 FARM ROAD 115
Mailing Address - Street 2:SUITE B
Mailing Address - City:MT VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:75457-7434
Mailing Address - Country:US
Mailing Address - Phone:903-588-2237
Mailing Address - Fax:903-588-2239
Practice Address - Street 1:1933 FARM ROAD 115
Practice Address - Street 2:SUITE B
Practice Address - City:MT VERNON
Practice Address - State:TX
Practice Address - Zip Code:75457-7434
Practice Address - Country:US
Practice Address - Phone:903-588-2237
Practice Address - Fax:903-588-2239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB145113Medicare PIN