Provider Demographics
NPI:1407909120
Name:BRIAN V JONGEWARD
Entity Type:Organization
Organization Name:BRIAN V JONGEWARD
Other - Org Name:CHIROCENTER ONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:V
Authorized Official - Last Name:JONGEWARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-775-0223
Mailing Address - Street 1:2812 17TH AVE S STE C
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4048
Mailing Address - Country:US
Mailing Address - Phone:701-775-0223
Mailing Address - Fax:701-738-0655
Practice Address - Street 1:2812 17TH AVE S STE C
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4048
Practice Address - Country:US
Practice Address - Phone:701-775-0223
Practice Address - Fax:701-738-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND611261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18728Medicaid
ND1407909120OtherCLINIC NPI
ND1376620831OtherINDIVIDUAL NPI
NDN70789Medicare ID - Type Unspecified
ND18728Medicaid