Provider Demographics
NPI:1134298979
Name:TIMOTHY R MCMULLEN DC PC
Entity type:Organization
Organization Name:TIMOTHY R MCMULLEN DC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MCMULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:816-781-1010
Mailing Address - Street 1:1508 MISSOURI ROUTE A
Mailing Address - Street 2:SUITE A
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-7129
Mailing Address - Country:US
Mailing Address - Phone:816-781-1010
Mailing Address - Fax:816-415-8487
Practice Address - Street 1:1508 MISSOURI ROUTE A
Practice Address - Street 2:SUITE A
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-7129
Practice Address - Country:US
Practice Address - Phone:816-781-1010
Practice Address - Fax:816-415-8487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006657111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7070138OtherAETNA PROVIDER NUMBER
MO25314026OtherBCBS PROVIDER NUMBER
MOU70653OtherHUMANA
MO25314026OtherBCBS PROVIDER NUMBER
MOT550000Medicare PIN