1457350332 NPI number — BURTIS CHIROPRACTIC CENTER PA

Table of content: (NPI 1457350332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457350332 NPI number — BURTIS CHIROPRACTIC CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BURTIS CHIROPRACTIC CENTER PA
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:
BURTIS CHIROPRACTIC CENTER
Provider Other Organization Name Type Code:
3
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:
1457350332
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 N STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRMONT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56031-4058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-235-5557
Provider Business Mailing Address Fax Number:
507-238-4429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 N STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56031-4058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-235-5557
Provider Business Practice Location Address Fax Number:
507-238-4429
Provider Enumeration Date:
07/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BURTIS
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT OF CORP, CLINIC DIRECTOR
Authorized Official Telephone Number:
507-235-5551

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2488 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 59662FA . This is a "INSURANCE ID #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3D578BU . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 551328600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com