Provider Demographics
NPI:1659562148
Name:CUSTOM CHIROPRACTIC CENTER LLC
Entity Type:Organization
Organization Name:CUSTOM CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ARVIL
Authorized Official - Middle Name:LONNIE
Authorized Official - Last Name:RUDD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:913-722-1113
Mailing Address - Street 1:6220 ANTIOCH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-2866
Mailing Address - Country:US
Mailing Address - Phone:913-722-1113
Mailing Address - Fax:913-722-2677
Practice Address - Street 1:6220 ANTIOCH RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66202-2866
Practice Address - Country:US
Practice Address - Phone:913-722-1113
Practice Address - Fax:913-722-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-04887111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
33911023OtherBLUE CROSS BLUE SHIELD
KSP00220339OtherRAILROAD MEDICARE
KSP00220339OtherRAILROAD MEDICARE
33911023OtherBLUE CROSS BLUE SHIELD