Provider Demographics
NPI:1760997506
Name:UPPER CERVICAL CLINIC OF NORTHWEST ARKANSAS
Entity Type:Organization
Organization Name:UPPER CERVICAL CLINIC OF NORTHWEST ARKANSAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHISM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:479-300-6031
Mailing Address - Street 1:110 SARATOGA WAY STE 5
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:AR
Mailing Address - Zip Code:72730-2908
Mailing Address - Country:US
Mailing Address - Phone:479-300-6031
Mailing Address - Fax:
Practice Address - Street 1:110 SARATOGA WAY STE 5
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-2908
Practice Address - Country:US
Practice Address - Phone:479-300-6031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR16130111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty