Provider Demographics
NPI:1295036630
Name:ELITE CHIROPRACTIC & TISSUE REHABILITATION, LLC
Entity Type:Organization
Organization Name:ELITE CHIROPRACTIC & TISSUE REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:STICKNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:308-455-1500
Mailing Address - Street 1:8 W 56TH ST
Mailing Address - Street 2:SUITE A1 EAST
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-0505
Mailing Address - Country:US
Mailing Address - Phone:308-455-1500
Mailing Address - Fax:308-455-1502
Practice Address - Street 1:8 W 56TH ST
Practice Address - Street 2:SUITE A1 EAST
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-0505
Practice Address - Country:US
Practice Address - Phone:308-455-1500
Practice Address - Fax:308-455-1502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE39261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1295036630Medicare NSC