Provider Demographics
NPI:1326125634
Name:STANICH, JON JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:JOSEPH
Last Name:STANICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36365
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-0365
Mailing Address - Country:US
Mailing Address - Phone:317-823-7000
Mailing Address - Fax:
Practice Address - Street 1:5674 CAITO DR
Practice Address - Street 2:SUITE 110
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-1375
Practice Address - Country:US
Practice Address - Phone:317-823-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001077111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100119420Medicaid
IN274850Medicare ID - Type Unspecified