1881870012 NPI number — WAYSON FAMILY CHIROPRACTIC PC

Table of content: (NPI 1881870012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881870012 NPI number — WAYSON FAMILY CHIROPRACTIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYSON FAMILY 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:
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:
1881870012
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4619 CHADWICK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR FALLS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50613-8060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-266-1119
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4619 CHADWICK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR FALLS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50613-8060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-266-1119
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/17/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WAYSON
Authorized Official First Name:
BLAKE
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
319-266-1119

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  06835 , 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: 07291 . This is a "BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0480830 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".