Healthcare Provider Details

I. General information

NPI: 1063703536
Provider Name (Legal Business Name): NORTHWEST CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2011
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 W 2ND ST
MARYVILLE MO
64468-2229
US

IV. Provider business mailing address

206 W 2ND ST
MARYVILLE MO
64468-2229
US

V. Phone/Fax

Practice location:
  • Phone: 660-582-8099
  • Fax:
Mailing address:
  • Phone: 660-582-8099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number006606
License Number StateMO

VIII. Authorized Official

Name: DR. VINCENT LOVELL SHELBY
Title or Position: DOCTOR/OWNER
Credential: D.C.
Phone: 660-582-8099