Provider Demographics
NPI:1477837615
Name:PRAIRIELANDS CHIROPRACTIC CLINIC P.C.
Entity Type:Organization
Organization Name:PRAIRIELANDS CHIROPRACTIC CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TONWEYA
Authorized Official - Middle Name:WILLOW
Authorized Official - Last Name:LANGILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:712-256-2561
Mailing Address - Street 1:300 W BROADWAY
Mailing Address - Street 2:SUITE 712
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-9078
Mailing Address - Country:US
Mailing Address - Phone:712-256-2561
Mailing Address - Fax:712-256-1927
Practice Address - Street 1:300 W BROADWAY
Practice Address - Street 2:SUITE 712
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-9078
Practice Address - Country:US
Practice Address - Phone:712-256-2561
Practice Address - Fax:712-256-1927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007034111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0400821Medicaid
NE10025584600Medicaid
NE10025584600Medicaid