=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689952335
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOSCIUSKO CHIROPRACTIC CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2011
-----------------------------------------------------
Last Update Date | 07/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 N MADISON ST
-----------------------------------------------------
City | KOSCIUSKO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39090-3626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-303-9830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 N MADISON ST
-----------------------------------------------------
City | KOSCIUSKO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39090-3626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FELICIA POE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 662-303-9830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | 1174
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------