Provider Demographics
NPI:1639344104
Name:NATIVE SOUL CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:NATIVE SOUL CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MGR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:505-327-7476
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-0270
Mailing Address - Country:US
Mailing Address - Phone:505-327-7476
Mailing Address - Fax:505-327-7389
Practice Address - Street 1:737 W ARRINGTON ST
Practice Address - Street 2:SUITE C
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5528
Practice Address - Country:US
Practice Address - Phone:505-327-7476
Practice Address - Fax:505-327-7389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1691111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty