Provider Demographics
NPI:1497077101
Name:MID-MISSOURI CLINIC OF CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:MID-MISSOURI CLINIC OF CHIROPRACTIC LLC
Other - Org Name:MID-MISSOURI CLINIC OF CHIROPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CAITLIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:HUNNICUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-256-6789
Mailing Address - Street 1:19 EAST WALNUT STREET
Mailing Address - Street 2:SUITE F
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-4505
Mailing Address - Country:US
Mailing Address - Phone:573-256-6789
Mailing Address - Fax:573-443-4821
Practice Address - Street 1:19 EAST WALNUT STREET
Practice Address - Street 2:SUITE F
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4505
Practice Address - Country:US
Practice Address - Phone:573-256-6789
Practice Address - Fax:573-443-4821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008027069305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1528396124Medicare PIN