1659605517 NPI number — CHIROMED CHIROPRACTIC PLLC

Table of content: (NPI 1659605517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659605517 NPI number — CHIROMED CHIROPRACTIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROMED CHIROPRACTIC PLLC
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:
1659605517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 STONECREST CT
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
SHELBYVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40065-8155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-647-4600
Provider Business Mailing Address Fax Number:
502-647-4607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4123 TAYLOR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40215-2341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-363-7172
Provider Business Practice Location Address Fax Number:
502-363-7174
Provider Enumeration Date:
09/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WIETFELDT
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
502-647-4600

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4867 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4568504744 . This is a "PERSONAL NPI" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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