Provider Demographics
NPI:1366750606
Name:NEW HAVEN CHIROPRACTIC CLINIC, LLC
Entity type:Organization
Organization Name:NEW HAVEN CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA,DC
Authorized Official - Phone:662-392-1608
Mailing Address - Street 1:PO BOX 1661
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38935-1661
Mailing Address - Country:US
Mailing Address - Phone:662-453-2250
Mailing Address - Fax:662-453-2280
Practice Address - Street 1:1707 STRONG AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-3923
Practice Address - Country:US
Practice Address - Phone:662-453-2250
Practice Address - Fax:662-453-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-21
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1146111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty