Healthcare Provider Details

I. General information

NPI: 1730144429
Provider Name (Legal Business Name): SOUTHERLAND CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 S WALDRON RD
FORT SMITH AR
72903-2583
US

IV. Provider business mailing address

1150 S WALDRON RD
FORT SMITH AR
72903-2583
US

V. Phone/Fax

Practice location:
  • Phone: 479-452-4433
  • Fax: 479-452-2355
Mailing address:
  • Phone: 479-452-4433
  • Fax: 479-452-2355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: MISS GRACE CONNER
Title or Position: INSURANCE CLERK/PRIVACY OFFICIAL
Credential:
Phone: 479-452-4433