Healthcare Provider Details

I. General information

NPI: 1821143009
Provider Name (Legal Business Name): MAGNA CHIRO MED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 AIRWAY DR SUITE B
BOWLING GREEN KY
42103-7125
US

IV. Provider business mailing address

2424 AIRWAY DR SUITE B
BOWLING GREEN KY
42103-7125
US

V. Phone/Fax

Practice location:
  • Phone: 270-746-9400
  • Fax: 270-746-0240
Mailing address:
  • Phone: 270-746-9400
  • Fax: 270-746-0240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4950
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. KELLI BROWN
Title or Position: OFFICE MANAGER
Credential:
Phone: 270-746-9400