Provider Demographics
NPI:1346655685
Name:COMFORT CHIROPRACTIC MASSAGE
Entity Type:Organization
Organization Name:COMFORT CHIROPRACTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYANT
Authorized Official - Middle Name:L
Authorized Official - Last Name:PONCHOT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-650-5028
Mailing Address - Street 1:8802 MADISON AVE STE F
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-6400
Mailing Address - Country:US
Mailing Address - Phone:317-650-5028
Mailing Address - Fax:
Practice Address - Street 1:8802 MADISON AVE STE F
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-6400
Practice Address - Country:US
Practice Address - Phone:317-650-5028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002296A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201024960Medicaid
IN201024960Medicaid