Provider Demographics
NPI:1962659748
Name:KADOLPH CHIROPRACTIC CLINIC PC
Entity type:Organization
Organization Name:KADOLPH CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KADOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-425-3312
Mailing Address - Street 1:1704 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:MO
Mailing Address - Zip Code:64424-2064
Mailing Address - Country:US
Mailing Address - Phone:660-425-3312
Mailing Address - Fax:
Practice Address - Street 1:1704 MAIN ST.
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424-2064
Practice Address - Country:US
Practice Address - Phone:660-425-3312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12301736111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT42399Medicare UPIN