Provider Demographics
NPI:1093085623
Name:R LAQUA PC
Entity Type:Organization
Organization Name:R LAQUA PC
Other - Org Name:YELLOWSTONE CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:LAQUA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-433-4757
Mailing Address - Street 1:222 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:MT
Mailing Address - Zip Code:59270-4020
Mailing Address - Country:US
Mailing Address - Phone:406-433-4757
Mailing Address - Fax:406-433-1131
Practice Address - Street 1:222 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:MT
Practice Address - Zip Code:59270-4020
Practice Address - Country:US
Practice Address - Phone:406-433-4757
Practice Address - Fax:406-433-1131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT986111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT40363OtherBCBS PROVIDER NUMBER
MTU86384Medicare UPIN
MTM000004476Medicare PIN