Provider Demographics
NPI:1497029243
Name:TONGANOXIE CHIROPRACTIC AND SOFT TISSUE REHAB
Entity Type:Organization
Organization Name:TONGANOXIE CHIROPRACTIC AND SOFT TISSUE REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:OLDS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:913-845-9000
Mailing Address - Street 1:307 RIDGE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-9304
Mailing Address - Country:US
Mailing Address - Phone:913-845-9000
Mailing Address - Fax:913-845-3305
Practice Address - Street 1:307 RIDGE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-9304
Practice Address - Country:US
Practice Address - Phone:913-845-9000
Practice Address - Fax:913-845-3305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-25
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05423111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
660128005Medicare PIN