Provider Demographics
NPI:1780876425
Name:SUMMIT FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:SUMMIT FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOUBA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:816-246-4325
Mailing Address - Street 1:312 NE HWY 291
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086
Mailing Address - Country:US
Mailing Address - Phone:816-246-4325
Mailing Address - Fax:
Practice Address - Street 1:312 NE HWY 291
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086
Practice Address - Country:US
Practice Address - Phone:816-246-4325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017439111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO34831017OtherBLUE SHIELD OF KANSAS CIT
MO34831017OtherBLUE SHIELD OF KANSAS CIT