Provider Demographics
NPI:1144495599
Name:D. J. FAHNESTOCK, D. C., P. C.
Entity type:Organization
Organization Name:D. J. FAHNESTOCK, D. C., P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JEWELL
Authorized Official - Last Name:FAHNESTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:660-886-6903
Mailing Address - Street 1:269 S JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-2134
Mailing Address - Country:US
Mailing Address - Phone:660-886-6903
Mailing Address - Fax:660-886-6904
Practice Address - Street 1:269 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-2134
Practice Address - Country:US
Practice Address - Phone:660-886-6903
Practice Address - Fax:660-886-6904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003184261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO03801016OtherBLUE CROSS BLUE SHIELD OF KC
MOT73635OtherUPIN
115444OtherHEALTHLINK
MA1033Medicare PIN