1477739795 NPI number — HEARTLAND CLINIC CHIROPRACTIC PC

Table of content: (NPI 1477739795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477739795 NPI number — HEARTLAND CLINIC CHIROPRACTIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND CLINIC CHIROPRACTIC PC
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:
HEARTLAND CLINIC OF CHIROPRACTIC
Provider Other Organization Name Type Code:
3
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:
1477739795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2525 DEMERS AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58201-8622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-746-5977
Provider Business Mailing Address Fax Number:
701-746-5976

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 DEMERS AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-8622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-746-5977
Provider Business Practice Location Address Fax Number:
701-746-5976
Provider Enumeration Date:
01/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KIEFAT
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
701-746-5977

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  726 , 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: 23135 . This is a "BCBS OF NORTH DAKOTA" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 064K8HE . This is a "BCBS OF MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 12742 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 622662100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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