Provider Demographics
NPI:1457303133
Name:JEFFERSON COUNTY CHIROPRACTIC INC
Entity Type:Organization
Organization Name:JEFFERSON COUNTY CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:LUNDERGAN
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:812-265-6141
Mailing Address - Street 1:110 HOLT DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250
Mailing Address - Country:US
Mailing Address - Phone:812-265-6141
Mailing Address - Fax:812-265-6318
Practice Address - Street 1:110 HOLT DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250
Practice Address - Country:US
Practice Address - Phone:812-265-6141
Practice Address - Fax:812-265-6318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001796111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5462620OtherAETNA PROVIDER ID
IN000000210323OtherANTHEM PROVIDER ID
IN192150Medicare ID - Type Unspecified