Provider Demographics
NPI:1154697910
Name:BOONEVILLE CHIROPRACTIC CLINIC, P.A.
Entity type:Organization
Organization Name:BOONEVILLE CHIROPRACTIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:BLYTHE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:662-728-7414
Mailing Address - Street 1:105B N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-3207
Mailing Address - Country:US
Mailing Address - Phone:662-728-7414
Mailing Address - Fax:662-728-4163
Practice Address - Street 1:105B N 2ND ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-3207
Practice Address - Country:US
Practice Address - Phone:662-728-7414
Practice Address - Fax:662-728-4163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS885261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS350000154Medicare PIN
MSU47118Medicare UPIN