Provider Demographics
NPI:1649355140
Name:FRACK CHIROPRACTIC & WELLNESS CENTER PC
Entity type:Organization
Organization Name:FRACK CHIROPRACTIC & WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:FRACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-673-5556
Mailing Address - Street 1:1506 S. MADISON STREET
Mailing Address - Street 2:
Mailing Address - City:WEBB CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64870-2901
Mailing Address - Country:US
Mailing Address - Phone:417-673-5556
Mailing Address - Fax:
Practice Address - Street 1:1506 S. MADISON STREET
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-2901
Practice Address - Country:US
Practice Address - Phone:417-673-5556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO6356111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014533Medicare ID - Type UnspecifiedMEDICARE