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General NPI Number Information
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NPI Number | 1154090710
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Entity Type | Organization
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Legal Business Name | BOONVILLE CHIROPRACTIC LLC
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Dates
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Enumeration Date | 09/08/2021
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Last Update Date | 09/08/2021
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Provider Practice Location Address
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Address Line | 321 MAIN ST
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City | BOONVILLE
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State | MO
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Zip | 65233-1565
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Country | US
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Telephone | 660-882-5775
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Fax |
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Provider Business Mailing Address
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Address Line | 321 MAIN ST
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City | BOONVILLE
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State | MO
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Zip | 65233-1565
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Country | US
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Telephone | 660-882-5775
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TANNER GREEN
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Credential | DC, ATC
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Telephone | 660-537-4773
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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