Provider Demographics
NPI:1467564187
Name:COYOTE CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:COYOTE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-242-3533
Mailing Address - Street 1:320 MAPLE AVE E
Mailing Address - Street 2:SUITE C
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4716
Mailing Address - Country:US
Mailing Address - Phone:703-242-3533
Mailing Address - Fax:703-242-3541
Practice Address - Street 1:320 MAPLE AVE E
Practice Address - Street 2:SUITE C
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4716
Practice Address - Country:US
Practice Address - Phone:703-242-3533
Practice Address - Fax:703-242-3541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556249111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherEMPLOYER TAX ID
G02442Medicare PIN