Provider Demographics
NPI:1164467486
Name:WATER'S EDGE CHIROPRACTIC & WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:WATER'S EDGE CHIROPRACTIC & WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:TRIPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-543-1955
Mailing Address - Street 1:2419 MULLAN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1827
Mailing Address - Country:US
Mailing Address - Phone:406-543-1955
Mailing Address - Fax:406-543-1506
Practice Address - Street 1:2419 MULLAN RD
Practice Address - Street 2:SUITE A
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1827
Practice Address - Country:US
Practice Address - Phone:406-543-1955
Practice Address - Fax:406-543-1506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1047111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1871546556OtherINDIVIDUAL NPI #
MT0166270Medicaid
MT0166260Medicaid
MT0166260Medicaid