Provider Demographics
NPI:1114002250
Name:MIDWAY CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:MIDWAY CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-890-6275
Mailing Address - Street 1:2021 HIGHWAY 130
Mailing Address - Street 2:
Mailing Address - City:BENNETT
Mailing Address - State:IA
Mailing Address - Zip Code:52721-9601
Mailing Address - Country:US
Mailing Address - Phone:563-890-6275
Mailing Address - Fax:
Practice Address - Street 1:2021 HIGHWAY 130
Practice Address - Street 2:
Practice Address - City:BENNETT
Practice Address - State:IA
Practice Address - Zip Code:52721-9601
Practice Address - Country:US
Practice Address - Phone:563-890-6275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06817111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0476648Medicaid
IA39898OtherBLUE CROSS BLUE SHIELD
IA0476648Medicaid
IAI15949Medicare ID - Type Unspecified