Provider Demographics
NPI:1609376730
Name:SOUTHEAST IOWA CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:SOUTHEAST IOWA CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:OVERTURF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:641-682-4476
Mailing Address - Street 1:104 ELMDALE AVE
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-1234
Mailing Address - Country:US
Mailing Address - Phone:641-682-4476
Mailing Address - Fax:641-682-4476
Practice Address - Street 1:104 ELMDALE AVE
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-1234
Practice Address - Country:US
Practice Address - Phone:641-682-4476
Practice Address - Fax:641-682-4476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007267111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0002556Medicaid