Provider Demographics
NPI:1356411276
Name:TWIN LAKES CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:TWIN LAKES CHIROPRACTIC CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LUDEAN
Authorized Official - Last Name:UNGERANK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:870-431-8900
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:AR
Mailing Address - Zip Code:72642-0148
Mailing Address - Country:US
Mailing Address - Phone:870-431-8900
Mailing Address - Fax:870-431-8810
Practice Address - Street 1:4898 HIGHWAY 178 WEST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:AR
Practice Address - Zip Code:72642
Practice Address - Country:US
Practice Address - Phone:870-431-8900
Practice Address - Fax:870-431-8810
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TWIN LAKES CHIROPRACTIC CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-08
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR904111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101032718Medicaid
ARDC2383OtherRAILROAD MEDICARE PIN
AR101032718Medicaid
ARDC2383OtherRAILROAD MEDICARE PIN
AR59910Medicare ID - Type Unspecified