Provider Demographics
NPI:1033146063
Name:WHITAKER, CRYSTAL IOLA (DC)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:IOLA
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:IOLA
Other - Last Name:CUNNINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:3309 LAKE TRENTON DR
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:64683-3228
Mailing Address - Country:US
Mailing Address - Phone:660-359-3500
Mailing Address - Fax:660-359-3511
Practice Address - Street 1:2910 OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MO
Practice Address - Zip Code:64683-3405
Practice Address - Country:US
Practice Address - Phone:660-359-3500
Practice Address - Fax:660-359-3511
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005035876111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOVO8611Medicare UPIN
MOT90E437Medicare ID - Type Unspecified