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General NPI Number Information
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NPI Number | 1194056200
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Entity Type | Organization
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Legal Business Name | CLASSIC CHIROPRACTIC CLINIC PC
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Dates
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Enumeration Date | 01/29/2010
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Last Update Date | 01/29/2010
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Provider Practice Location Address
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Address Line | 401 N UNION AVE
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City | ROSWELL
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State | NM
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Zip | 88201-3948
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Country | US
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Telephone | 575-623-9983
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Fax | 575-623-9982
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Provider Business Mailing Address
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Address Line | 401 N UNION AVE
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City | ROSWELL
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State | NM
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Zip | 88201-3948
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Country | US
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Telephone | 575-623-9983
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ROBERT WAYNE WHITED
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Credential | DC
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Telephone | 575-623-9983
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 590
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License Number State | NM
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