Provider Demographics
NPI:1821133638
Name:KILGORE CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:KILGORE CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:COTTIER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-984-4432
Mailing Address - Street 1:316 N HENDERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-2712
Mailing Address - Country:US
Mailing Address - Phone:903-984-4432
Mailing Address - Fax:903-984-1023
Practice Address - Street 1:316 N HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-2712
Practice Address - Country:US
Practice Address - Phone:903-984-4432
Practice Address - Fax:903-984-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2872111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0025QUOtherBCBS
TX001199101Medicaid
TX350005434OtherRAILROAD MEDICARE
TXTXB115245Medicare PIN
TX0025QUOtherBCBS
TX601258Medicare PIN