Provider Demographics
NPI:1891336707
Name:FORM JOINT & MUSCLE SPECIALISTS
Entity Type:Organization
Organization Name:FORM JOINT & MUSCLE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:316-361-0620
Mailing Address - Street 1:1145 N ANDOVER RD STE 109
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-8902
Mailing Address - Country:US
Mailing Address - Phone:316-361-0620
Mailing Address - Fax:
Practice Address - Street 1:1145 N ANDOVER RD STE 109
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-8902
Practice Address - Country:US
Practice Address - Phone:316-361-0620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1033535695Medicaid