Provider Demographics
NPI:1679887624
Name:CHIROPRACTIC LIFE CENTER POPLAR BLUFF PC
Entity Type:Organization
Organization Name:CHIROPRACTIC LIFE CENTER POPLAR BLUFF PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HONOMICHL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:573-686-1118
Mailing Address - Street 1:408 VINE ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-5838
Mailing Address - Country:US
Mailing Address - Phone:573-686-1118
Mailing Address - Fax:573-686-5109
Practice Address - Street 1:408 VINE ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-5838
Practice Address - Country:US
Practice Address - Phone:573-686-1118
Practice Address - Fax:573-686-5109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005891111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty