Provider Demographics
NPI:1619159969
Name:KNOXVILLE CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:KNOXVILLE CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FORMANEK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:641-842-3007
Mailing Address - Street 1:115 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50138-2525
Mailing Address - Country:US
Mailing Address - Phone:641-842-3007
Mailing Address - Fax:641-842-5612
Practice Address - Street 1:115 E MAIN ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IA
Practice Address - Zip Code:50138-2525
Practice Address - Country:US
Practice Address - Phone:641-842-3007
Practice Address - Fax:641-842-5612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05434111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty