Provider Demographics
NPI:1700151255
Name:MISSION SQUARE CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:MISSION SQUARE CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:TRENT
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:334-676-0166
Mailing Address - Street 1:PO BOX 20572
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36120-0572
Mailing Address - Country:US
Mailing Address - Phone:800-764-0911
Mailing Address - Fax:800-764-8611
Practice Address - Street 1:49 MITCHELL DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-2923
Practice Address - Country:US
Practice Address - Phone:800-764-0911
Practice Address - Fax:800-764-8611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty