1629195342 NPI number — HEALTH AND WELLNESS CHIROPRACTIC

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 1629195342 NPI number — HEALTH AND WELLNESS CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTH AND WELLNESS CHIROPRACTIC
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:
6
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:
1629195342
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
448 21ST ST W STE D2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DICKINSON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58601-2647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-483-6325
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
448 21ST ST W STE D2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DICKINSON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58601-2647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-483-6325
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DORVAL
Authorized Official First Name:
TODD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
701-483-6325

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  738 AND 742 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 13483 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06241-001 . This is a "BLUE CROSS BLUE SHIELD ND" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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