Provider Demographics
NPI:1508148131
Name:MONTGOMERY COUNTY CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:MONTGOMERY COUNTY CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:EDGECOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:765-359-3330
Mailing Address - Street 1:1408 DARLINGTON AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-2056
Mailing Address - Country:US
Mailing Address - Phone:765-359-3330
Mailing Address - Fax:765-359-3332
Practice Address - Street 1:1408 DARLINGTON AVE
Practice Address - Street 2:SUITE G
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-2056
Practice Address - Country:US
Practice Address - Phone:765-359-3330
Practice Address - Fax:765-359-3332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002570A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center