Provider Demographics
NPI:1083276885
Name:WAUKEE CHIROPRACTIC AND ACUPUNCTURE PLLC
Entity Type:Organization
Organization Name:WAUKEE CHIROPRACTIC AND ACUPUNCTURE PLLC
Other - Org Name:ADVANCED CHIROPRACTIC AND ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARETH
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:LOURENS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:515-987-1290
Mailing Address - Street 1:1218 SE UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-8831
Mailing Address - Country:US
Mailing Address - Phone:515-987-1290
Mailing Address - Fax:
Practice Address - Street 1:1218 SE UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263-8831
Practice Address - Country:US
Practice Address - Phone:712-299-1527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-01
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0410942Medicaid