Provider Demographics
NPI:1700207933
Name:GIBSON CHIROPRACTIC CLINIC JODI PEDERSEN GENERAL PARTNER
Entity Type:Organization
Organization Name:GIBSON CHIROPRACTIC CLINIC JODI PEDERSEN GENERAL PARTNER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:L
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:816-883-8585
Mailing Address - Street 1:28B WESTWOODS DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-3519
Mailing Address - Country:US
Mailing Address - Phone:816-883-8585
Mailing Address - Fax:816-883-8588
Practice Address - Street 1:28B WESTWOODS DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-3519
Practice Address - Country:US
Practice Address - Phone:816-883-8585
Practice Address - Fax:816-883-8588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012033593111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty