Provider Demographics
NPI:1093953374
Name:HUDSON FAMILY CHIROPRACTIC, PLC
Entity Type:Organization
Organization Name:HUDSON FAMILY CHIROPRACTIC, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:GROOTHUIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:319-988-3336
Mailing Address - Street 1:P.O. BOX 366
Mailing Address - Street 2:107 ELDORA RD.
Mailing Address - City:HUDSON
Mailing Address - State:IA
Mailing Address - Zip Code:50643-0366
Mailing Address - Country:US
Mailing Address - Phone:319-988-3336
Mailing Address - Fax:319-988-3196
Practice Address - Street 1:107 ELDORA RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:IA
Practice Address - Zip Code:50643-0366
Practice Address - Country:US
Practice Address - Phone:319-988-3336
Practice Address - Fax:319-988-3196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03028111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0016899Medicaid
IAT00199Medicare UPIN
IA0016899Medicaid