Provider Demographics
NPI:1326181835
Name:VAN DEN BERGHE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:VAN DEN BERGHE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:VAN DEN BERGHE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-886-3636
Mailing Address - Street 1:114 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IA
Mailing Address - Zip Code:52772-1728
Mailing Address - Country:US
Mailing Address - Phone:563-886-3636
Mailing Address - Fax:563-886-3555
Practice Address - Street 1:114 W 5TH ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IA
Practice Address - Zip Code:52772-1728
Practice Address - Country:US
Practice Address - Phone:563-886-3636
Practice Address - Fax:563-886-3555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06950111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0747881Medicaid
IAI19975Medicare PIN