Provider Demographics
NPI:1407037765
Name:COSGROVE CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:COSGROVE CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:COSGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:641-684-2261
Mailing Address - Street 1:1429 ALBIA RD
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-3946
Mailing Address - Country:US
Mailing Address - Phone:641-684-2261
Mailing Address - Fax:641-684-2254
Practice Address - Street 1:1429 ALBIA RD
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-3946
Practice Address - Country:US
Practice Address - Phone:641-684-2261
Practice Address - Fax:641-684-2254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0289660Medicaid
IAI6944Medicare PIN