Provider Demographics
NPI:1851530257
Name:WOMACK CHIROPRACTIC CENTER, PC
Entity Type:Organization
Organization Name:WOMACK CHIROPRACTIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:JANELL
Authorized Official - Last Name:NICKELS-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-967-4606
Mailing Address - Street 1:PO BOX 17
Mailing Address - Street 2:118 W. MAIN ST
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483
Mailing Address - Country:US
Mailing Address - Phone:417-967-4606
Mailing Address - Fax:417-967-5915
Practice Address - Street 1:118 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483
Practice Address - Country:US
Practice Address - Phone:417-967-4606
Practice Address - Fax:417-967-5915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCE004121111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000030676Medicare PIN
MOT78500Medicare UPIN