1699738039 NPI number — HOMETOWN CHIROPRACTIC LLC

Table of content: (NPI 1699738039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699738039 NPI number — HOMETOWN CHIROPRACTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOMETOWN CHIROPRACTIC LLC
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:
HOMETOWN CHIROPRACTIC
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:
1699738039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 N 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSKALOOSA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52577-2812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-676-1400
Provider Business Mailing Address Fax Number:
641-676-1401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 N 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OSKALOOSA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52577-2812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-676-1400
Provider Business Practice Location Address Fax Number:
641-676-1401
Provider Enumeration Date:
04/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EBELSHEISER
Authorized Official First Name:
JASON
Authorized Official Middle Name:
DANIEL
Authorized Official Title or Position:
PRINCIPAL
Authorized Official Telephone Number:
641-676-1400

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  06743 , 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: 0452748 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0479006 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38214 . This is a "BLUE CROSS BLUE SHIEL ID" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 246032 . This is a "MIDLANDS CHOICE ID" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".