Provider Demographics
NPI:1639433295
Name:KUPERUS FAMILY CHIROPRACTIC PSC
Entity Type:Organization
Organization Name:KUPERUS FAMILY CHIROPRACTIC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:KUPERUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:502-426-6715
Mailing Address - Street 1:105 LYNDON LN
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5550
Mailing Address - Country:US
Mailing Address - Phone:502-426-6715
Mailing Address - Fax:502-426-6716
Practice Address - Street 1:105 LYNDON LN
Practice Address - Street 2:SUITE 102
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5550
Practice Address - Country:US
Practice Address - Phone:502-426-6715
Practice Address - Fax:502-426-6716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5228111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200977090Medicaid
KY7100131790Medicaid
IN200977090Medicaid