1255631404 NPI number — CROSS TRAINERS CHIROPRACTIC AND WELLNESS CENTER

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 1255631404 NPI number — CROSS TRAINERS CHIROPRACTIC AND WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSS TRAINERS CHIROPRACTIC AND WELLNESS CENTER
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:
1255631404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31454 VETERANS MEMORIAL HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TERRA ALTA
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26764-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-789-3153
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31454 VETERANS MEMORIAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRA ALTA
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26764-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-789-3153
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FRIEND
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/CHIROPRACTIC PHYSICIAN
Authorized Official Telephone Number:
304-789-3153

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  690 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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