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General NPI Number Information
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NPI Number | 1760997506
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Entity Type | Organization
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Legal Business Name | UPPER CERVICAL CLINIC OF NORTHWEST ARKANSAS
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Dates
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Enumeration Date | 12/01/2017
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Last Update Date | 12/01/2017
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Provider Practice Location Address
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Address Line | 110 SARATOGA WAY STE 5
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City | FARMINGTON
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State | AR
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Zip | 72730-2908
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Country | US
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Telephone | 479-300-6031
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Fax |
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Provider Business Mailing Address
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Address Line | 110 SARATOGA WAY STE 5
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City | FARMINGTON
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State | AR
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Zip | 72730-2908
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Country | US
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Telephone | 479-300-6031
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JACKSON CHISM
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Credential | DC
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Telephone | 479-300-6031
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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 | 16130
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License Number State | AR
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