Provider Demographics
NPI:1629228283
Name:ADVANCED CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:ADVANCED CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KIDGELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:970-871-4644
Mailing Address - Street 1:PO BOX 883245
Mailing Address - Street 2:
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80488
Mailing Address - Country:US
Mailing Address - Phone:970-871-4644
Mailing Address - Fax:970-871-6774
Practice Address - Street 1:1755 CENTRAL PARK DRIVE
Practice Address - Street 2:#130
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80487
Practice Address - Country:US
Practice Address - Phone:970-871-4644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6106111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1720170434Medicare PIN