Healthcare Provider Details

I. General information

NPI: 1568392041
Provider Name (Legal Business Name): MARY MEDOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 VIRGINIA AVENUE
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

411 WALNUT STREET PMB: 24928
GREEN COVE SPRINGS FL
32043
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-2663
  • Fax:
Mailing address:
  • Phone: 440-571-1385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2026020985
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: