Provider Demographics
NPI:1285760884
Name:PUCKETT, CHRISTOPHER JAMES (DC)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:JAMES
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2345
Mailing Address - Country:US
Mailing Address - Phone:601-545-1481
Mailing Address - Fax:601-545-1449
Practice Address - Street 1:130 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2345
Practice Address - Country:US
Practice Address - Phone:601-545-1481
Practice Address - Fax:601-545-1449
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1035111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS35-000-0295Medicare ID - Type Unspecified
MSU93587Medicare UPIN