Provider Demographics
NPI:1730505876
Name:BOONEVILLE CHIROPRACTIC, INC
Entity type:Organization
Organization Name:BOONEVILLE CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:479-675-4253
Mailing Address - Street 1:.P.O BOX 597
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72927
Mailing Address - Country:US
Mailing Address - Phone:479-675-4253
Mailing Address - Fax:
Practice Address - Street 1:181 WEST 6TH STREET
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72927
Practice Address - Country:US
Practice Address - Phone:479-675-4253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1290261Q00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR130690718Medicaid
55977Medicare PIN
AR55977Medicare UPIN