Provider Demographics
NPI:1477736015
Name:EDISS CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:EDISS CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:F
Authorized Official - Last Name:LISCO-EDISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-358-5066
Mailing Address - Street 1:1330 E RICHARDS ST
Mailing Address - Street 2:P.O. BOX 902
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-2951
Mailing Address - Country:US
Mailing Address - Phone:307-358-3147
Mailing Address - Fax:307-358-3213
Practice Address - Street 1:1330 E RICHARDS ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2951
Practice Address - Country:US
Practice Address - Phone:307-358-3147
Practice Address - Fax:307-358-3213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY574111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
03753001OtherBCBS CLINIC
WY0554501OtherWORKERS COMPENSATION
WY0554501OtherWORKERS COMPENSATION
U68799Medicare UPIN