Provider Demographics
NPI:1831255116
Name:ALLIANCE CHIROPRACTIC OF SE, LLC
Entity type:Organization
Organization Name:ALLIANCE CHIROPRACTIC OF SE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOSEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:KHANI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:502-367-2112
Mailing Address - Street 1:10701 W MANSLICK ROAD
Mailing Address - Street 2:
Mailing Address - City:FAIRDALE
Mailing Address - State:KY
Mailing Address - Zip Code:40118
Mailing Address - Country:US
Mailing Address - Phone:502-367-2112
Mailing Address - Fax:502-367-7799
Practice Address - Street 1:10701 W MANSLICK RD
Practice Address - Street 2:
Practice Address - City:FAIRDALE
Practice Address - State:KY
Practice Address - Zip Code:40118-9581
Practice Address - Country:US
Practice Address - Phone:502-367-2112
Practice Address - Fax:502-367-7799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4056111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000108878OtherANTHEM
KY350053484OtherRAILROAD MEDICARE
KY1150522OtherPASSPORT MEDICAID
KY85001568Medicaid
KY6090001Medicare PIN