Provider Demographics
NPI:1003003534
Name:ETHERIDGE CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:ETHERIDGE CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:W
Authorized Official - Last Name:ETHERIDGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:812-232-8803
Mailing Address - Street 1:631 S 25TH STREET
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803
Mailing Address - Country:US
Mailing Address - Phone:812-232-8803
Mailing Address - Fax:812-232-1305
Practice Address - Street 1:631 S 25TH STREET
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803
Practice Address - Country:US
Practice Address - Phone:812-232-8803
Practice Address - Fax:812-232-1305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2009-07-10
Deactivation Date:2008-01-09
Deactivation Code:
Reactivation Date:2009-07-10
Provider Licenses
StateLicense IDTaxonomies
IN08001352111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100252800AMedicaid
IN08001352OtherALL OTHER MAJOR MED
IN598223ZOtherAETNA
IN000000093143OtherANTHEM BCBS