1689743478 NPI number — MIDWAY CHIROPRACTIC LLC

Table of content: DR. ANNA LUISA DI LORENZO MD (NPI 1982689170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689743478 NPI number — MIDWAY CHIROPRACTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWAY CHIROPRACTIC LLC
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:
1689743478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 STATE ST
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
BETTENDORF
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52722-5195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-323-1551
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 STATE ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
BETTENDORF
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52722-5195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-323-1551
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PRATT
Authorized Official First Name:
TARA
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
DOCTOR OF CHIROPRACTIC
Authorized Official Telephone Number:
563-323-1551

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  06817 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39899 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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