Provider Demographics
NPI:1871189340
Name:DR MUKAIA MITCHOM LOCKETT LLC
Entity Type:Organization
Organization Name:DR MUKAIA MITCHOM LOCKETT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MUKAIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHOM LOCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-606-9119
Mailing Address - Street 1:2 EAGLE CTR STE 1
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1847
Mailing Address - Country:US
Mailing Address - Phone:618-606-9119
Mailing Address - Fax:877-781-4222
Practice Address - Street 1:2 EAGLE CTR STE 1
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1847
Practice Address - Country:US
Practice Address - Phone:618-606-9119
Practice Address - Fax:877-781-4222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-17
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty