Provider Demographics
NPI:1083048482
Name:PHORMATION CHIROPRACTIC
Entity Type:Organization
Organization Name:PHORMATION CHIROPRACTIC
Other - Org Name:PHORMATION CHIROPRACTIC & DAY SPA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CINIC DIRECTOR / OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HEATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-262-9222
Mailing Address - Street 1:36304 KENAI SPUR HWY
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669
Mailing Address - Country:US
Mailing Address - Phone:907-262-9222
Mailing Address - Fax:907-262-9212
Practice Address - Street 1:36304 KENAI SPUR HWY
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:907-262-9222
Practice Address - Fax:907-262-9212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-21
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK923462111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty