1083735583 NPI number — FAMILY CHIROPRACTIC CLINIC INC

Table of content: (NPI 1083735583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083735583 NPI number — FAMILY CHIROPRACTIC CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY CHIROPRACTIC CLINIC INC
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:
MADISON CHIROPRACTIC NORTH
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:
1083735583
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2205 N SHERMAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53704-3310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-244-0044
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2205 N SHERMAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53704-3310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-244-0044
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCNABB
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
608-244-0044

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1579 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1346212099 . This is a "DANIEL SODERHOLM NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38777500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1083686737 . This is a "ROSS ROYSTER NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1356313001 . This is a "BRENT MCNABB NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1692 . This is a "DANIEL SODERHOLM LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38767300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1579 . This is a "BRENT MCNABB LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38767400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1619 . This is a "ROSS ROYSTER LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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