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General NPI Number Information
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NPI Number | 1659562148
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Entity Type | Organization
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Legal Business Name | CUSTOM CHIROPRACTIC CENTER LLC
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Dates
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Enumeration Date | 08/08/2007
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 6220 ANTIOCH RD SUITE 200
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City | SHAWNEE MISSION
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State | KS
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Zip | 66202-2866
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Country | US
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Telephone | 913-722-1113
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Fax | 913-722-2677
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Provider Business Mailing Address
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Address Line | 6220 ANTIOCH RD SUITE 200
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City | SHAWNEE MISSION
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State | KS
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Zip | 66202-2866
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Country | US
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Telephone | 913-722-1113
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Fax | 913-722-2677
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ARVIL LONNIE RUDD
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Credential | D.C.
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Telephone | 913-722-1113
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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 | 01-04887
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License Number State | KS
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