Provider Demographics
NPI:1629116322
Name:PEAVY CHIROPRACTIC CLINIC PA
Entity Type:Organization
Organization Name:PEAVY CHIROPRACTIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC-TRES
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PEAVY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-268-9093
Mailing Address - Street 1:2409 MAMIE ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7345
Mailing Address - Country:US
Mailing Address - Phone:601-582-3343
Mailing Address - Fax:601-583-6655
Practice Address - Street 1:2409 MAMIE ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7345
Practice Address - Country:US
Practice Address - Phone:601-582-3343
Practice Address - Fax:601-583-6655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC00559OtherMEDICARE GROUP #
MS353484066OtherBLUE CROSS & BLUE SHIELD
MSC00559OtherMEDICARE GROUP #
MS=========OtherUNITED HEALTHCARE