Provider Demographics
NPI:1285627521
Name:LISBON CHIROPRACTIC CLINIC PLLC
Entity Type:Organization
Organization Name:LISBON CHIROPRACTIC CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-683-4582
Mailing Address - Street 1:PO BOX 255
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-0255
Mailing Address - Country:US
Mailing Address - Phone:701-683-4582
Mailing Address - Fax:701-683-5814
Practice Address - Street 1:906 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4333
Practice Address - Country:US
Practice Address - Phone:701-683-4582
Practice Address - Fax:701-683-5814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND562111N00000X
ND640111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
31B45LIOtherBLUE SELECT GROUP NUMBER
ND11490Medicaid
ND11490Medicaid