Provider Demographics
NPI:1730144429
Name:SOUTHERLAND CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:SOUTHERLAND CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK/PRIVACY OFFICIAL
Authorized Official - Prefix:MISS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-452-4433
Mailing Address - Street 1:1150 S WALDRON RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2583
Mailing Address - Country:US
Mailing Address - Phone:479-452-4433
Mailing Address - Fax:479-452-2355
Practice Address - Street 1:1150 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2583
Practice Address - Country:US
Practice Address - Phone:479-452-4433
Practice Address - Fax:479-452-2355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B095Medicare ID - Type UnspecifiedGROUP/CLINIC NUMBER