1295869998 NPI number — VAN CHIROPRACTIC CLINIC, PC

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 1295869998 NPI number — VAN CHIROPRACTIC CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VAN CHIROPRACTIC CLINIC, PC
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:
1295869998
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1644 BROADWATER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BILLINGS
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59102-5004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-656-7000
Provider Business Mailing Address Fax Number:
406-656-8729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1644 BROADWATER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BILLINGS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59102-5004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-656-7000
Provider Business Practice Location Address Fax Number:
406-656-8729
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
GREY
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
406-656-7000

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  645 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CJ5000 . This is a "MEDICARE RR GROUP #" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 41261 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 1750339164 . This is a "NPI # INDIVIDUAL FOR DR" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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