Provider Demographics
NPI:1609065416
Name:RIVERTON CHIROPRACTIC CLINIC P C.
Entity Type:Organization
Organization Name:RIVERTON CHIROPRACTIC CLINIC P C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:307-856-4945
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-0079
Mailing Address - Country:US
Mailing Address - Phone:307-856-4945
Mailing Address - Fax:307-856-4945
Practice Address - Street 1:1221 EAST MAIN
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4544
Practice Address - Country:US
Practice Address - Phone:307-856-4945
Practice Address - Fax:307-856-4945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYWY513111N00000X
WY513111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW305714Medicare PIN
WYW14803Medicare UPIN