1477581478 NPI number — EVANSDALE CHIROPRACTIC CLINIC, PLC

Table of content: (NPI 1477581478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477581478 NPI number — EVANSDALE CHIROPRACTIC CLINIC, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVANSDALE CHIROPRACTIC CLINIC, PLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477581478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 S EVANS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSDALE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50707-1121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-234-4872
Provider Business Mailing Address Fax Number:
319-236-0670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 S EVANS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSDALE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50707-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-234-4872
Provider Business Practice Location Address Fax Number:
319-236-0670
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIDEN
Authorized Official First Name:
DUANE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
319-234-4872

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  A5374 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0287854 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com