MEDICARE: SOUTHERLAND CHIROPRACTIC CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1730144429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERLAND CHIROPRACTIC CLINIC

Provider Business Mailing Address
First Line	:	1150 S WALDRON RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-2583
Country	:	US
Telephone Number	:	479-452-4433
Fax Number	:	479-452-2355

Provider Business Practice Location Address
First Line	:	1150 S WALDRON RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-2583
Country	:	US
Telephone Number	:	479-452-4433
Fax Number	:	479-452-2355

Authorized Official
Title or Position	:	INSURANCE CLERK/PRIVACY OFFICIAL
Name	:	MISS GRACE CONNER
Credential	:
Telephone Number	:	479-452-4433

Provider Enumeration Date	:	04/18/2006
Last Update Date	:	08/22/2020

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Directions to “SOUTHERLAND CHIROPRACTIC CLINIC ” Practice Location

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