Provider Demographics
NPI:1508850256
Name:BLACKMON CHIROPRACTIC CLINIC, P.A.
Entity Type:Organization
Organization Name:BLACKMON CHIROPRACTIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:ROYSE
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:501-663-4101
Mailing Address - Street 1:7000 CANTRELL RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-4139
Mailing Address - Country:US
Mailing Address - Phone:501-663-4101
Mailing Address - Fax:501-663-7526
Practice Address - Street 1:7000 CANTRELL RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-4139
Practice Address - Country:US
Practice Address - Phone:501-663-4101
Practice Address - Fax:501-663-7526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1383111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR57695Medicare ID - Type UnspecifiedCHIROPRACTIC