Provider Demographics
NPI:1073786653
Name:15TH STREET CHIROPRACTIC PC
Entity Type:Organization
Organization Name:15TH STREET CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:HERTENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-771-1222
Mailing Address - Street 1:222 15TH ST S
Mailing Address - Street 2:SUITE C
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-2459
Mailing Address - Country:US
Mailing Address - Phone:406-771-1222
Mailing Address - Fax:406-771-1225
Practice Address - Street 1:222 15TH ST S
Practice Address - Street 2:SUITE C
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-2459
Practice Address - Country:US
Practice Address - Phone:406-771-1222
Practice Address - Fax:406-771-1225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT537261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0164398Medicaid
MT40763OtherBLUE CROSS/BLUE SHIELD