Provider Demographics
NPI:1356466445
Name:KIST FAMILY CHIROPRACTIC & WELLNESS CENTRE INC.
Entity Type:Organization
Organization Name:KIST FAMILY CHIROPRACTIC & WELLNESS CENTRE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:KIST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:440-428-0711
Mailing Address - Street 1:2711 HUBBARD RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057
Mailing Address - Country:US
Mailing Address - Phone:440-428-0711
Mailing Address - Fax:440-428-0760
Practice Address - Street 1:2711 HUBBARD RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057
Practice Address - Country:US
Practice Address - Phone:440-428-0711
Practice Address - Fax:440-428-0760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2823111N00000X
OH2827111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2174749Medicaid
OH2174749Medicaid
U79691Medicare UPIN
U79692Medicare UPIN
OH0A4015691Medicare ID - Type UnspecifiedDR TARA OAKEY KIST