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General NPI Number Information
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NPI Number | 1881965283
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Entity Type | Organization
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Legal Business Name | DESUTTER CHIROPRACTIC CLINIC, INC.
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Dates
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Enumeration Date | 01/18/2012
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Last Update Date | 01/18/2012
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Provider Practice Location Address
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Address Line | 9659 GOODMAN RD
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-1725
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Country | US
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Telephone | 662-895-2501
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Fax | 662-895-3464
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Provider Business Mailing Address
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Address Line | 9659 GOODMAN RD
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-1725
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Country | US
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Telephone | 662-895-2501
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Fax | 662-895-3464
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Authorized Official
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Title or Position | CHIRPRACTOR'S ASST
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Name | MS. RACHEL BUMPOUS
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Credential |
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Telephone | 662-895-2501
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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 | 0059
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License Number State | MS
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