Provider Demographics
NPI:1063837367
Name:COUNTRYSIDE CLINIC OF CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:COUNTRYSIDE CLINIC OF CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJTIRANUKUL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-496-6030
Mailing Address - Street 1:990 BELVEDERE DR STE B
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-1193
Mailing Address - Country:US
Mailing Address - Phone:513-836-8844
Mailing Address - Fax:513-836-8845
Practice Address - Street 1:990 BELVEDERE DR STE B
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-1193
Practice Address - Country:US
Practice Address - Phone:513-836-8844
Practice Address - Fax:513-836-8845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-23
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4008111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty