Provider Demographics
NPI:1821143009
Name:MAGNA CHIRO MED, LLC
Entity Type:Organization
Organization Name:MAGNA CHIRO MED, LLC
Other - Org Name:MAGNA CHIROPRACTIC, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-746-9400
Mailing Address - Street 1:2424 AIRWAY DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7125
Mailing Address - Country:US
Mailing Address - Phone:270-746-9400
Mailing Address - Fax:270-746-0240
Practice Address - Street 1:2424 AIRWAY DR
Practice Address - Street 2:SUITE B
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7125
Practice Address - Country:US
Practice Address - Phone:270-746-9400
Practice Address - Fax:270-746-0240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4950111N00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85003317Medicaid
KY1285629154OtherNPI
KY85003762Medicaid
KY1396723755OtherNPI
KY1821143009OtherCLINIC NPI
KY85003762Medicaid
KY1821143009OtherCLINIC NPI
KY1285629154OtherNPI
KY85003317Medicaid