Provider Demographics
NPI:1790308054
Name:FULLY KNOWN CHIROPRACTIC
Entity Type:Organization
Organization Name:FULLY KNOWN CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:LEWALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-872-7728
Mailing Address - Street 1:1351 TILDEN RD
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:MO
Mailing Address - Zip Code:65656-8633
Mailing Address - Country:US
Mailing Address - Phone:417-872-7728
Mailing Address - Fax:
Practice Address - Street 1:714 STATE HIGHWAY 248 STE 503
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-3761
Practice Address - Country:US
Practice Address - Phone:417-872-7728
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty