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General NPI Number Information
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NPI Number | 1205228244
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Entity Type | Organization
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Legal Business Name | IMAGE CHIROPRACTIC PC
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Dates
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Enumeration Date | 02/27/2015
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Last Update Date | 02/12/2020
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Provider Practice Location Address
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Address Line | 2709 E LIBERTY ST
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City | MEXICO
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State | MO
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Zip | 65265-3556
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Country | US
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Telephone | 573-581-2446
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Fax | 573-581-2448
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Provider Business Mailing Address
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Address Line | 2709 E LIBERTY ST
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City | MEXICO
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State | MO
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Zip | 65265-3556
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Country | US
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Telephone | 573-581-2446
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Fax | 573-581-2448
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MILES GOINS
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Credential | DC
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Telephone | 573-581-2446
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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 | 2011039597
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License Number State | MO
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