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General NPI Number Information
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NPI Number | 1609354844
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Entity Type | Organization
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Legal Business Name | OAK GROVE CHIROPRACTIC LLC
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Dates
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Enumeration Date | 07/31/2018
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Last Update Date | 12/10/2018
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Provider Practice Location Address
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Address Line | 705 S BROADWAY
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City | OAK GROVE
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State | MO
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Zip | 64075-8102
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Country | US
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Telephone | 816-625-1598
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Fax | 816-625-1599
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Provider Business Mailing Address
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Address Line | 705 S BROADWAY
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City | OAK GROVE
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State | MO
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Zip | 64075-8102
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Country | US
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Telephone | 816-625-1598
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Fax | 816-625-1599
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Authorized Official
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Title or Position | CO-OWNER/ PRACTICING DOCTOR
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Name | DR. JESSICA LYNN VANDERKLEI
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Credential | DC
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Telephone | 816-625-1598
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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 | 2017033050
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License Number State | MO
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