Provider Demographics
NPI:1477581478
Name:EVANSDALE CHIROPRACTIC CLINIC, PLC
Entity Type:Organization
Organization Name:EVANSDALE CHIROPRACTIC CLINIC, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WIDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC/DI BCN
Authorized Official - Phone:319-234-4872
Mailing Address - Street 1:209 S EVANS RD
Mailing Address - Street 2:
Mailing Address - City:EVANSDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50707-1121
Mailing Address - Country:US
Mailing Address - Phone:319-234-4872
Mailing Address - Fax:319-236-0670
Practice Address - Street 1:209 S EVANS RD
Practice Address - Street 2:
Practice Address - City:EVANSDALE
Practice Address - State:IA
Practice Address - Zip Code:50707-1121
Practice Address - Country:US
Practice Address - Phone:319-234-4872
Practice Address - Fax:319-236-0670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA5374111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0287854Medicaid
IA0287854Medicaid