Provider Demographics
NPI:1659567857
Name:GUTSHALL CLINIC OF CHIROPRACTIC P.C.
Entity Type:Organization
Organization Name:GUTSHALL CLINIC OF CHIROPRACTIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:GUTSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:816-632-6611
Mailing Address - Street 1:602 LANA DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CAMERON
Mailing Address - State:MO
Mailing Address - Zip Code:64429-1473
Mailing Address - Country:US
Mailing Address - Phone:816-632-6611
Mailing Address - Fax:816-632-6612
Practice Address - Street 1:602 LANA DR
Practice Address - Street 2:SUITE A
Practice Address - City:CAMERON
Practice Address - State:MO
Practice Address - Zip Code:64429-1473
Practice Address - Country:US
Practice Address - Phone:816-632-6611
Practice Address - Fax:816-632-6612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003906111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO75346700Medicaid
MO75346700Medicaid
MO0003355BMedicare PIN