Provider Demographics
NPI:1942873294
Name:ADVANCE CHIROPRACTIC AND PERFORMANCE
Entity Type:Organization
Organization Name:ADVANCE CHIROPRACTIC AND PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BILLY
Authorized Official - Middle Name:DEREK
Authorized Official - Last Name:HUDDLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:501-366-1919
Mailing Address - Street 1:11900 PLEASANT RIDGE RD APT 1322
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-2486
Mailing Address - Country:US
Mailing Address - Phone:501-366-1919
Mailing Address - Fax:
Practice Address - Street 1:301 N SHACKLEFORD RD STE F1
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2887
Practice Address - Country:US
Practice Address - Phone:501-404-8910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-22
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty