Provider Demographics
NPI:1942380423
Name:SOUTHSIDE CHIROPRACTIC PSC
Entity Type:Organization
Organization Name:SOUTHSIDE CHIROPRACTIC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:R
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:859-373-0800
Mailing Address - Street 1:3198 CUSTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4000
Mailing Address - Country:US
Mailing Address - Phone:859-373-0800
Mailing Address - Fax:859-255-4104
Practice Address - Street 1:3198 CUSTER DR STE 100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4000
Practice Address - Country:US
Practice Address - Phone:859-373-0800
Practice Address - Fax:859-255-4104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000209773OtherBCBS
KY85002269Medicaid
U89236Medicare UPIN
KY000000209773OtherBCBS