Provider Demographics
NPI:1619298395
Name:GREGORY CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:GREGORY CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:MILTON
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:601-373-5767
Mailing Address - Street 1:5604 I 55 S
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-9402
Mailing Address - Country:US
Mailing Address - Phone:601-373-5767
Mailing Address - Fax:601-372-4031
Practice Address - Street 1:5604 I 55 S
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-9402
Practice Address - Country:US
Practice Address - Phone:601-373-5767
Practice Address - Fax:601-372-4031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS589111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00035227OtherRAILROAD MEDICARE
MS08737729Medicaid
MS350000018Medicare PIN
MSP00035227OtherRAILROAD MEDICARE