Provider Demographics
NPI:1184103376
Name:PERRY COUNTY CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:PERRY COUNTY CHIROPRACTIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:214-632-9022
Mailing Address - Street 1:103 PARK DR
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-7407
Mailing Address - Country:US
Mailing Address - Phone:501-851-6685
Mailing Address - Fax:501-851-6495
Practice Address - Street 1:130 HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72126-9451
Practice Address - Country:US
Practice Address - Phone:501-889-5555
Practice Address - Fax:501-851-6495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-09
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR16033111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty