=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891392817
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MASON COFFMAN DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2020
-----------------------------------------------------
Last Update Date | 09/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 N ORANGE ST
-----------------------------------------------------
City | BUTLER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64730-1319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-679-0077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 209 N ORANGE ST
-----------------------------------------------------
City | BUTLER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64730-1319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-940-5505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2020030904
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------