1316271539 NPI number — PRO-MOTION CHIROPRACTIC AND REHABILITATION

Table of content: (NPI 1316271539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316271539 NPI number — PRO-MOTION CHIROPRACTIC AND REHABILITATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRO-MOTION CHIROPRACTIC AND REHABILITATION
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:
1316271539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12743
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83002-2743
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-699-3170
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4030 W LAKE CREEK DR
Provider Second Line Business Practice Location Address:
STE. 9
Provider Business Practice Location Address City Name:
WILSON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83014-9689
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-699-3170
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HANDSCHIN
Authorized Official First Name:
JEREMIAH
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
307-699-3170

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  681 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: W24372 . This is a "PTAN" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com