Provider Demographics
NPI:1689957433
Name:CROCKER CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:CROCKER CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:D
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-532-9166
Mailing Address - Street 1:464 N JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-2742
Mailing Address - Country:US
Mailing Address - Phone:417-532-9166
Mailing Address - Fax:417-532-9887
Practice Address - Street 1:464 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-2742
Practice Address - Country:US
Practice Address - Phone:417-532-9166
Practice Address - Fax:417-532-9887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO004819111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000030053Medicare UPIN