Provider Demographics
NPI:1477883676
Name:CORNELIUS CHIROPRACTIC CENTRE, LTD.
Entity Type:Organization
Organization Name:CORNELIUS CHIROPRACTIC CENTRE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:CORNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:319-895-6392
Mailing Address - Street 1:321 HILLVIEW DR SE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IA
Mailing Address - Zip Code:52314-9717
Mailing Address - Country:US
Mailing Address - Phone:319-895-6392
Mailing Address - Fax:
Practice Address - Street 1:216 2ND ST SW
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IA
Practice Address - Zip Code:52314-1630
Practice Address - Country:US
Practice Address - Phone:319-895-6392
Practice Address - Fax:319-895-6167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1023143Medicaid
IAT00280Medicare UPIN
IA1023143Medicaid