Provider Demographics
NPI:1164607362
Name:RUBY MOUNTAIN CHIROPRACTIC CENTER, INC.
Entity Type:Organization
Organization Name:RUBY MOUNTAIN CHIROPRACTIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:S
Authorized Official - Last Name:WENDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:775-777-3045
Mailing Address - Street 1:123 SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-3614
Mailing Address - Country:US
Mailing Address - Phone:775-777-3033
Mailing Address - Fax:775-777-3045
Practice Address - Street 1:123 SECOND STREET
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-3614
Practice Address - Country:US
Practice Address - Phone:775-777-3033
Practice Address - Fax:775-777-3045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB01082111N00000X
NVB736111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV39296Medicare PIN