Provider Demographics
NPI:1083735336
Name:ABC FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:ABC FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWIRE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:606-788-0015
Mailing Address - Street 1:PO BOX 708
Mailing Address - Street 2:705 BROADWAY
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-0708
Mailing Address - Country:US
Mailing Address - Phone:606-788-0015
Mailing Address - Fax:606-788-0015
Practice Address - Street 1:705 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1513
Practice Address - Country:US
Practice Address - Phone:606-788-0015
Practice Address - Fax:606-788-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4591111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85000552Medicaid
KYU81891Medicare UPIN
KY6089601Medicare PIN