1992900393 NPI number — SHEYENNE VALLEY CHIROPRACTIC CLINIC INC

Table of content: (NPI 1992900393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992900393 NPI number — SHEYENNE VALLEY CHIROPRACTIC CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHEYENNE VALLEY CHIROPRACTIC CLINIC INC
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:
1992900393
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 11 AVENUE WEST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LISBON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58054-0722
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-683-5337
Provider Business Mailing Address Fax Number:
701-683-0096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 11 AVENUE WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LISBON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58054-0722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-683-5337
Provider Business Practice Location Address Fax Number:
701-683-0096
Provider Enumeration Date:
06/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SANDNESS RIEGER
Authorized Official First Name:
JODI
Authorized Official Middle Name:
K
Authorized Official Title or Position:
SEC TRES CO OWNER
Authorized Official Telephone Number:
701-683-5337

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  533 553 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12687 12688 . This is a "BLUE SHIELD OF ND" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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