Provider Demographics
NPI:1043539448
Name:FITCH CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:FITCH CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:K
Authorized Official - Last Name:FITCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:260-471-7493
Mailing Address - Street 1:3010 E. STATE BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4700
Mailing Address - Country:US
Mailing Address - Phone:260-471-7493
Mailing Address - Fax:260-471-6935
Practice Address - Street 1:3010 E. STATE BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4700
Practice Address - Country:US
Practice Address - Phone:260-471-7493
Practice Address - Fax:260-471-6935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000206A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100049760Medicaid
IN350664222OtherMEDICARE RR
IN100049760Medicaid