Provider Demographics
NPI:1639242431
Name:BRACKEEN CHIROPRACTIC PA
Entity Type:Organization
Organization Name:BRACKEEN CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BRACKEEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:316-789-8100
Mailing Address - Street 1:320 N. ROCK RD SUITE 300
Mailing Address - Street 2:BRACKEEN CHIROPRACTIC
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037
Mailing Address - Country:US
Mailing Address - Phone:316-789-8100
Mailing Address - Fax:316-789-9400
Practice Address - Street 1:320 N. ROCK RD SUITE 300
Practice Address - Street 2:BRACKEEN CHIROPRACTIC
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037
Practice Address - Country:US
Practice Address - Phone:316-789-8100
Practice Address - Fax:316-789-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLIC-4-08-2400111N00000X
KS04628111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS060929Medicare UPIN