1295012219 NPI number — RIVER CITY CHIROPRACTIC 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 1295012219 NPI number — RIVER CITY CHIROPRACTIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVER CITY CHIROPRACTIC 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:
1295012219
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 GREEN ST
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
ONALASKA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54650-3329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-408-2488
Provider Business Mailing Address Fax Number:
855-545-8127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 GREEN ST
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
ONALASKA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54650-3329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-799-6442
Provider Business Practice Location Address Fax Number:
855-545-8127
Provider Enumeration Date:
11/04/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
COREY
Authorized Official Middle Name:
STEPHEN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
608-408-2488

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  5034 , 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)