Basic Information
| Provider Information | |||||||||
| NPI: | 1528556032 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRATED MEDICINE AND CHIROPRACTIC REGENERATION CENTER | ||||||||
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| OtherOrganizationName: | TONY DELK CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2725 JAMES SANDERS BLVD. | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420018501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705545114 | ||||||||
| FaxNumber: | 2702154834 | ||||||||
| Practice Location | |||||||||
| Address1: | 2537 LARKIN RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595450043 | ||||||||
| FaxNumber: | 5022649500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2018 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | MUSGROVE | ||||||||
| AuthorizedOfficialFirstName: | MANIKA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8595450043 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTEGRATED MEDICINE AND CHIROPRACTIC REGENERATION CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 207T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.