1144203183 NPI number — PORTER COUNTY CHIROPRACTIC CLINIC INC.

Table of content: (NPI 1144203183)

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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