Provider Demographics
NPI:1396303822
Name:EASTPORT CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:EASTPORT CHIROPRACTIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYRECE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:816-277-6815
Mailing Address - Street 1:4025 NE LAKEWOOD WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-2058
Mailing Address - Country:US
Mailing Address - Phone:816-598-4363
Mailing Address - Fax:816-709-3074
Practice Address - Street 1:4025 NE LAKEWOOD WAY STE 100
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-2058
Practice Address - Country:US
Practice Address - Phone:816-598-4363
Practice Address - Fax:816-709-3074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-30
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
50218029OtherBLUE CROSS OF KANSAS CITY