=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285437632
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CHIROPRACTIC OF THE 4 STATES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2025
-----------------------------------------------------
Last Update Date | 07/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3301 N RANGE LINE RD
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64801-9765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-206-2225
-----------------------------------------------------
Fax | 417-206-2227
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3301 N RANGE LINE RD
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64801-9765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-206-2225
-----------------------------------------------------
Fax | 417-206-2227
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RUSSELL EARL MCDANIEL
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 417-206-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------