Provider Demographics
NPI:1205038023
Name:VAN DAM CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:VAN DAM CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:VAN DAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-280-2599
Mailing Address - Street 1:1203 28TH ST S STE B
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8711
Mailing Address - Country:US
Mailing Address - Phone:701-532-5320
Mailing Address - Fax:701-280-2915
Practice Address - Street 1:1203 28TH ST S STE B
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8711
Practice Address - Country:US
Practice Address - Phone:701-532-5320
Practice Address - Fax:701-280-2915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND747305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1750343877OtherIND PROVIDER
NDU74232Medicare UPIN
ND1750343877OtherIND PROVIDER