Provider Demographics
NPI:1861690067
Name:LUCEDALE CHIROPRACTIC CLINIC, P.A.
Entity Type:Organization
Organization Name:LUCEDALE CHIROPRACTIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:601-947-8472
Mailing Address - Street 1:789 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-5729
Mailing Address - Country:US
Mailing Address - Phone:601-947-8472
Mailing Address - Fax:601-947-1672
Practice Address - Street 1:789 WINTER ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-5729
Practice Address - Country:US
Practice Address - Phone:601-947-8472
Practice Address - Fax:601-947-1672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS610111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06421772Medicaid
MSC02839OtherMEDICARE GROUP #
MST21180Medicare UPIN