Provider Demographics
NPI:1962465187
Name:BOOTHE CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:BOOTHE CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:BOOTHE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:276-783-7005
Mailing Address - Street 1:642 NORTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354
Mailing Address - Country:US
Mailing Address - Phone:276-783-7005
Mailing Address - Fax:276-783-8080
Practice Address - Street 1:642 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354
Practice Address - Country:US
Practice Address - Phone:276-783-7005
Practice Address - Fax:276-783-8080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555931111N00000X
VA0104556300111N00000X
VA0104001760111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06880Medicare PIN