Provider Demographics
NPI:1629195342
Name:HEALTH AND WELLNESS CHIROPRACTIC
Entity Type:Organization
Organization Name:HEALTH AND WELLNESS CHIROPRACTIC
Other - Org Name:HEALTH & WELLNESS CHIROPRACTIC CENTER LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DORVAL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-483-6325
Mailing Address - Street 1:448 21ST ST W STE D2
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2647
Mailing Address - Country:US
Mailing Address - Phone:701-483-6325
Mailing Address - Fax:
Practice Address - Street 1:448 21ST ST W STE D2
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-2647
Practice Address - Country:US
Practice Address - Phone:701-483-6325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND738 AND 742111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13483Medicaid
ND06241-001OtherBLUE CROSS BLUE SHIELD ND
ND13483Medicaid