Healthcare Provider Details

I. General information

NPI: 1639474349
Provider Name (Legal Business Name): GREEN FAMILY CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 03/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 N BELT HWY STE C
SAINT JOSEPH MO
64506-3081
US

IV. Provider business mailing address

1338 N BELT HWY STE C
SAINT JOSEPH MO
64506-3081
US

V. Phone/Fax

Practice location:
  • Phone: 816-387-8994
  • Fax: 816-387-8220
Mailing address:
  • Phone: 816-387-8994
  • Fax: 816-387-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number2011000648
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number2011000648
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2011000648
License Number StateMO

VIII. Authorized Official

Name: CRYSTAL M GREEN
Title or Position: OWNER
Credential: DC
Phone: 816-387-8994