Provider Demographics
NPI:1700052644
Name:SOUTHGATE CHIROPRACTIC INC.
Entity Type:Organization
Organization Name:SOUTHGATE CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:859-572-0029
Mailing Address - Street 1:2306 ALEXANDRIA PIKE
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:KY
Mailing Address - Zip Code:41071-3234
Mailing Address - Country:US
Mailing Address - Phone:859-572-0029
Mailing Address - Fax:859-572-0263
Practice Address - Street 1:2306 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:KY
Practice Address - Zip Code:41071-3234
Practice Address - Country:US
Practice Address - Phone:859-572-0029
Practice Address - Fax:859-572-0263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4453111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85001436Medicaid
OH40076493500OtherOHIO BWC
KY85001436Medicaid