Healthcare Provider Details

I. General information

NPI: 1235319708
Provider Name (Legal Business Name): NORTHWEST CHIROPRACTIC CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 11/15/2007
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: 660-582-5161
Mailing address:
  • Phone: 660-582-8099
  • Fax: 660-582-5161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. KEVAN J. EVANS
Title or Position: DOCTOR OF CHIROPRACTIC
Credential: DC
Phone: 660-582-8099