=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174086920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN KEY HAVEN CHIROPRACTIC AND BODYWORK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2019
-----------------------------------------------------
Last Update Date | 04/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 W BRIDLESPUR DR
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64114-5061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-383-6858
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 W BRIDLESPUR DR
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64114-5061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-383-6858
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR AND BODYWORKER
-----------------------------------------------------
Name | DR. JACOB R CHAMBERS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 660-383-6858
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------