Provider Demographics
NPI:1689952335
Name:KOSCIUSKO CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:KOSCIUSKO CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:POE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:662-303-9830
Mailing Address - Street 1:235 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:235 N MADISON ST
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3626
Practice Address - Country:US
Practice Address - Phone:662-303-9830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1174302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization