# COUNTRYSIDE CLINIC OF CHIROPRACTIC, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1063837367
- **Authorized official:** DR. TONY DEJTIRANUKUL D.C. (OWNER)
- **Authorized official phone:** (314) 496-6030

## Contact information

- **Practice address:** 990 BELVEDERE DR STE B, LEBANON, OH 45036-1193
- **Practice address phone:** (513) 836-8844
- **Practice address fax:** (513) 836-8845
- **Mailing address:** 990 BELVEDERE DR STE B, LEBANON, OH 45036-1193
- **Mailing address phone:** (513) 836-8844
- **Mailing address fax:** (513) 836-8845

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 111N00000X | Chiropractor | 4008 | OH | Yes |

## Other

- **Enumeration date:** 02/23/2014
- **Last updated:** 11/26/2019