Provider Demographics
NPI:1972544344
Name:MID-SOUTH CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:MID-SOUTH CHIROPRACTIC, LLC
Other - Org Name:MIDSOUTH CHIROPRACTIC & THERAPEUTIC MASSAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LAWTON
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:662-890-0012
Mailing Address - Street 1:6253 GOODMAN ROAD
Mailing Address - Street 2:SUITE A & B
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-9391
Mailing Address - Country:US
Mailing Address - Phone:662-890-0012
Mailing Address - Fax:662-890-0522
Practice Address - Street 1:6253 GOODMAN ROAD
Practice Address - Street 2:SUITE A & B
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-9391
Practice Address - Country:US
Practice Address - Phone:662-890-0012
Practice Address - Fax:662-890-0522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1518111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
701292OtherUNITED HEALTH CARE
7696844OtherAETNA
MS409574769OtherBLUE CROSS BLUE SHIELD MS
0111474OtherCIGNA
701292OtherGOLDEN RULE
701292OtherGE WELLNESS PLAN
4131570OtherBLUE CROSS BLUE SHIELD TN
4131570OtherBLUE CROSS BLUE SHIELD TN