Provider Demographics
NPI:1871660852
Name:EMMANUEL RIDGE CHIROPRACTIC SERVICES
Entity Type:Organization
Organization Name:EMMANUEL RIDGE CHIROPRACTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:601-709-3304
Mailing Address - Street 1:2073 HIGHWAY 49 S
Mailing Address - Street 2:SUITE C
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-9422
Mailing Address - Country:US
Mailing Address - Phone:601-709-3304
Mailing Address - Fax:601-709-3308
Practice Address - Street 1:2073 HIGHWAY 49 S
Practice Address - Street 2:SUITE C
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-9422
Practice Address - Country:US
Practice Address - Phone:601-709-3304
Practice Address - Fax:601-709-3308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0972111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0120084Medicaid