Provider Demographics
NPI:1629318159
Name:COFFEYVILLE CHIROPRACTIC
Entity Type:Organization
Organization Name:COFFEYVILLE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAEGER
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:TVEDTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:620-688-6159
Mailing Address - Street 1:411 1/2 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-5020
Mailing Address - Country:US
Mailing Address - Phone:620-688-6159
Mailing Address - Fax:620-688-6159
Practice Address - Street 1:411 1/2 W 11TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-5020
Practice Address - Country:US
Practice Address - Phone:620-688-6159
Practice Address - Fax:620-688-6159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-20
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05505111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty