Provider Demographics
NPI:1497949523
Name:COUNTRYSIDE CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:COUNTRYSIDE CHIROPRACTIC, PC
Other - Org Name:CRIST FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CRIST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:402-826-5097
Mailing Address - Street 1:1106 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:NE
Mailing Address - Zip Code:68333-2258
Mailing Address - Country:US
Mailing Address - Phone:402-826-5097
Mailing Address - Fax:402-826-5200
Practice Address - Street 1:1106 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:NE
Practice Address - Zip Code:68333-2258
Practice Address - Country:US
Practice Address - Phone:402-826-5097
Practice Address - Fax:402-826-5200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE970111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NED09554OtherBCBS
NED09554OtherBCBS