Provider Demographics
NPI:1992221741
Name:HEABERLIN CHIROPRACTIC & ACUPUNCTURE LLC
Entity Type:Organization
Organization Name:HEABERLIN CHIROPRACTIC & ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:HEABERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MTAA
Authorized Official - Phone:859-893-8184
Mailing Address - Street 1:904 COUNTRY OAKS DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8492
Mailing Address - Country:US
Mailing Address - Phone:859-893-8184
Mailing Address - Fax:
Practice Address - Street 1:1311 FORUM DR STE A
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2519
Practice Address - Country:US
Practice Address - Phone:573-340-3199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011003626111N00000X
KY5500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100402910Medicaid