Provider Demographics
NPI:1942587092
Name:CROSS CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:CROSS CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:660-359-4491
Mailing Address - Street 1:1200 E. 9TH ST.
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:64683
Mailing Address - Country:US
Mailing Address - Phone:660-359-4491
Mailing Address - Fax:
Practice Address - Street 1:1200 E 9TH ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MO
Practice Address - Zip Code:64683-2626
Practice Address - Country:US
Practice Address - Phone:660-359-4491
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011030716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty