Provider Demographics
NPI:1770709321
Name:WHITE RIVER CHIROPRACTIC LIFE CENTER, INC.
Entity type:Organization
Organization Name:WHITE RIVER CHIROPRACTIC LIFE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:870-698-1650
Mailing Address - Street 1:PO BOX 2544
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72503-2544
Mailing Address - Country:US
Mailing Address - Phone:870-698-1650
Mailing Address - Fax:870-793-4790
Practice Address - Street 1:1361 WHITE DR
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-9467
Practice Address - Country:US
Practice Address - Phone:870-698-1650
Practice Address - Fax:870-793-4790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR940111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F871OtherMEDICARE PTAN (LEGACY NUMBER)
AR127932718Medicaid