Provider Demographics
NPI:1588812580
Name:DIMOND CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:DIMOND CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:907-790-3371
Mailing Address - Street 1:750 W DIMOND BLVD STE #121
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-1515
Mailing Address - Country:US
Mailing Address - Phone:907-344-0033
Mailing Address - Fax:907-344-6332
Practice Address - Street 1:750 W DIMOND BLVD STE #121
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-1515
Practice Address - Country:US
Practice Address - Phone:907-344-0033
Practice Address - Fax:907-344-6332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 225100000X
AK105677261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1684500Medicaid
1679613483OtherPROVIDER NPI