1083735583 NPI number — FAMILY CHIROPRACTIC CLINIC INC

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 1083735583 NPI number — FAMILY CHIROPRACTIC CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY 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:
6
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:
1083735583
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2205 N SHERMAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53704-3310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-244-0044
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2205 N SHERMAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53704-3310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-244-0044
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCNABB
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
608-244-0044

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1579 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1346212099 . This is a "DANIEL SODERHOLM NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38777500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1083686737 . This is a "ROSS ROYSTER NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1356313001 . This is a "BRENT MCNABB NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1692 . This is a "DANIEL SODERHOLM LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38767300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1579 . This is a "BRENT MCNABB LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38767400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1619 . This is a "ROSS ROYSTER LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com