Provider Demographics
NPI:1235314071
Name:RETTAY CHIROPRACTIC OFFICE PSC
Entity Type:Organization
Organization Name:RETTAY CHIROPRACTIC OFFICE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:859-525-7117
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:7560 B BURLINGTON PIKE
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-9634
Mailing Address - Country:US
Mailing Address - Phone:859-525-7117
Mailing Address - Fax:859-282-3343
Practice Address - Street 1:7560 B BURLINGTON PIKE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-9634
Practice Address - Country:US
Practice Address - Phone:859-525-7117
Practice Address - Fax:859-282-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4396261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center