1497870653 NPI number — SOUTH DES MOINES CHIROPRACTIC

Table of content: (NPI 1497870653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497870653 NPI number — SOUTH DES MOINES CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH DES MOINES CHIROPRACTIC
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:
1497870653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 SW 9TH ST
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50315-7676
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-244-1823
Provider Business Mailing Address Fax Number:
515-244-4887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 SW 9TH ST STE 3
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50315-7666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-244-1823
Provider Business Practice Location Address Fax Number:
515-244-4887
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NEIL
Authorized Official First Name:
SARA
Authorized Official Middle Name:
LYNNAE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
515-244-1823

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  A05847 , 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: 0129692 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 19819 . This is a "INS ID" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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