Healthcare Provider Details

I. General information

NPI: 1871189340
Provider Name (Legal Business Name): DR MUKAIA MITCHOM LOCKETT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 EAGLE CTR STE 1
O FALLON IL
62269-1847
US

IV. Provider business mailing address

2 EAGLE CTR STE 1
O FALLON IL
62269-1847
US

V. Phone/Fax

Practice location:
  • Phone: 618-606-9119
  • Fax: 877-781-4222
Mailing address:
  • Phone: 618-606-9119
  • Fax: 877-781-4222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. MUKAIA MITCHOM LOCKETT
Title or Position: OWNER
Credential: DC
Phone: 618-606-9119