Basic Information
| Provider Information | |||||||||
| NPI: | 1700065018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOXWORTH | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2470 FLOWOOD DR | ||||||||
| Address2: | STE 125 | ||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019329201 | ||||||||
| FaxNumber: | 6019324962 | ||||||||
| Practice Location | |||||||||
| Address1: | 2470 FLOWOOD DR | ||||||||
| Address2: | STE 125 | ||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019329201 | ||||||||
| FaxNumber: | 6019324962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2007 | ||||||||
| LastUpdateDate: | 06/08/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 718 | MS | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 00117752 | 05 | MS | MEDICAID |