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General NPI Number Information
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NPI Number | 1942587092
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Entity Type | Organization
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Legal Business Name | CROSS CHIROPRACTIC CLINIC LLC
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Dates
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Enumeration Date | 11/03/2011
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Last Update Date | 11/03/2011
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Provider Practice Location Address
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Address Line | 1200 E 9TH ST
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City | TRENTON
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State | MO
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Zip | 64683-2626
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Country | US
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Telephone | 660-359-4491
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Fax |
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Provider Business Mailing Address
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Address Line | 1200 E. 9TH ST.
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City | TRENTON
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State | MO
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Zip | 64683
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Country | US
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Telephone | 660-359-4491
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. ETHAN CROSS
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Credential | D.C.
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Telephone | 660-359-4491
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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 | 2011030716
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License Number State | MO
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