1144203183 NPI number — PORTER COUNTY 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 1144203183 NPI number — PORTER COUNTY CHIROPRACTIC CLINIC INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTER COUNTY 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:
1144203183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1009
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALPARAISO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46384-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-465-5015
Provider Business Mailing Address Fax Number:
219-548-3828

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 ROOSEVELT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALPARAISO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46383-0970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-465-5015
Provider Business Practice Location Address Fax Number:
219-548-3828
Provider Enumeration Date:
11/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BEAUVAIS
Authorized Official First Name:
DALE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
219-465-5015

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  08001767A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 350049047 . This is a "RR MEDICARE GROUP NO" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 90000986 . This is a "IL BC/BS GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 000000105239 . This is a "ANTHEM GROUP NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200208460A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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