Provider Demographics
NPI:1033318530
Name:PROCHIROPRACTIC, PC
Entity Type:Organization
Organization Name:PROCHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILHELM
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCEP
Authorized Official - Phone:406-388-9915
Mailing Address - Street 1:8757 N JACKRABBIT LANE
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714
Mailing Address - Country:US
Mailing Address - Phone:406-388-9915
Mailing Address - Fax:406-388-9916
Practice Address - Street 1:8757 N JACKRABBIT LANE
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714
Practice Address - Country:US
Practice Address - Phone:406-388-9915
Practice Address - Fax:406-388-9916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT108065111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VO2939Medicare UPIN