1366654543 NPI number — 1ST AVENUE CHIROPRACTIC, P.C.

Table of content: (NPI 1366654543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366654543 NPI number — 1ST AVENUE CHIROPRACTIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
1ST AVENUE CHIROPRACTIC, P.C.
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:
1366654543
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:
611 1 ST AVE CHIROPRACTIC
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUMBOLDT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-332-5414
Provider Business Mailing Address Fax Number:
515-332-5415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 1 ST AVE CHIROPRACTIC
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-332-5414
Provider Business Practice Location Address Fax Number:
515-332-5415
Provider Enumeration Date:
05/03/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CROWLEY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
515-332-5414

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  A5718 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0279810 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".