Provider Demographics
NPI:1790979474
Name:ODESSA CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:ODESSA CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KESEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:816-633-5355
Mailing Address - Street 1:216 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076
Mailing Address - Country:US
Mailing Address - Phone:816-633-5355
Mailing Address - Fax:816-633-5356
Practice Address - Street 1:216 S 2ND ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076-1248
Practice Address - Country:US
Practice Address - Phone:816-633-5355
Practice Address - Fax:816-633-5356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO8420000AMedicare PIN