Provider Demographics
NPI:1235489048
Name:PRAIRIELAND CHIROPRACTIC P C
Entity Type:Organization
Organization Name:PRAIRIELAND CHIROPRACTIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:STAUDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:641-756-3740
Mailing Address - Street 1:133 W MAIN AVE
Mailing Address - Street 2:P.O. BOX 575
Mailing Address - City:ROCKFORD
Mailing Address - State:IA
Mailing Address - Zip Code:50468-7719
Mailing Address - Country:US
Mailing Address - Phone:641-756-3653
Mailing Address - Fax:641-756-3722
Practice Address - Street 1:133 W MAIN AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IA
Practice Address - Zip Code:50468-7719
Practice Address - Country:US
Practice Address - Phone:641-756-3653
Practice Address - Fax:641-756-3722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05231111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA41891OtherBC/BS PROVIDER NUMBER
IA41891OtherMEDICARE PTAN
IAP00070391OtherPALMETTO GBA PROV. NUMBER
IA1242305Medicaid
IA1242305Medicaid