Provider Demographics
NPI:1487601084
Name:PICAYUNE CHIROPRACTIC CLINIC INC
Entity type:Organization
Organization Name:PICAYUNE CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICCO
Authorized Official - Middle Name:VITO
Authorized Official - Last Name:IMPASTATO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:601-889-1633
Mailing Address - Street 1:214 N CURRAN AVE
Mailing Address - Street 2:SUITE E1
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-4002
Mailing Address - Country:US
Mailing Address - Phone:601-889-1633
Mailing Address - Fax:601-889-1633
Practice Address - Street 1:214 N CURRAN AVE
Practice Address - Street 2:SUITE E1
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-4002
Practice Address - Country:US
Practice Address - Phone:601-889-1633
Practice Address - Fax:604-889-1633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1093111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
V05902Medicare UPIN