1003125121 NPI number — CHIRO ONE WELLNESS CENTER OF NICHOLASVILLE PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003125121 NPI number — CHIRO ONE WELLNESS CENTER OF NICHOLASVILLE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIRO ONE WELLNESS CENTER OF NICHOLASVILLE PLLC
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:
1003125121
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3786 SOLUTIONS CTR
Provider Second Line Business Mailing Address:
#773786
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-320-6400
Provider Business Mailing Address Fax Number:
630-320-6489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 EDGEWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NICHOLASVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40356-2261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-885-5020
Provider Business Practice Location Address Fax Number:
859-885-5050
Provider Enumeration Date:
10/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WANG
Authorized Official First Name:
SAM
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
630-468-1824

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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