Provider Demographics
NPI:1487042438
Name:KILLDEER CHIROPRACTIC ACUPUNCTURE & BODYWORK
Entity Type:Organization
Organization Name:KILLDEER CHIROPRACTIC ACUPUNCTURE & BODYWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WETZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-764-7227
Mailing Address - Street 1:PO BOX 902
Mailing Address - Street 2:
Mailing Address - City:KILLDEER
Mailing Address - State:ND
Mailing Address - Zip Code:58640-0902
Mailing Address - Country:US
Mailing Address - Phone:701-764-7227
Mailing Address - Fax:
Practice Address - Street 1:42 CENTRAL AVE S
Practice Address - Street 2:
Practice Address - City:KILLDEER
Practice Address - State:ND
Practice Address - Zip Code:58640-4000
Practice Address - Country:US
Practice Address - Phone:701-764-7227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND977111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty