1821030297 NPI number — STREETSBORO CHIROPRACTIC CLINIC

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 1821030297 NPI number — STREETSBORO CHIROPRACTIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STREETSBORO CHIROPRACTIC CLINIC
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:
1821030297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2067
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STREETSBORO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44241-0067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-626-5561
Provider Business Mailing Address Fax Number:
330-626-9219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9125 STATE ROUTE 14
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STREETSBORO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44241-5629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-626-5561
Provider Business Practice Location Address Fax Number:
330-626-9219
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHEAT
Authorized Official First Name:
GARY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
330-626-5561

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  907 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0473232 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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