1710506282 NPI number — NATURALLY COMPLETE CHIROPRACTIC SPA

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 1710506282 NPI number — NATURALLY COMPLETE CHIROPRACTIC SPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NATURALLY COMPLETE CHIROPRACTIC SPA
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:
1710506282
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6747 W PHILADELPHIA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCCORDSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46055-9490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-340-3865
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1803 BROAD RIPPLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46220-2339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-537-5681
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2020

Additional Information

Authorized Official

Authorized Official Last Name:
HENRY-GRAVES
Authorized Official First Name:
TENIKA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
317-536-5781

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300035553 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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