Provider Demographics
NPI:1659581049
Name:FAMILY CHIROPRACTIC CENTER OF ST. PAUL, P.C.
Entity Type:Organization
Organization Name:FAMILY CHIROPRACTIC CENTER OF ST. PAUL, P.C.
Other - Org Name:FAMILY CHIROPRACTIC CENTER OF ST. PAUL, P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:TRAUDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:308-754-5515
Mailing Address - Street 1:207 HOWARD AVE.
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:NE
Mailing Address - Zip Code:68873
Mailing Address - Country:US
Mailing Address - Phone:308-381-2029
Mailing Address - Fax:
Practice Address - Street 1:207 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:NE
Practice Address - Zip Code:68873-2120
Practice Address - Country:US
Practice Address - Phone:308-381-2029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1305111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE099307Medicare PIN
NE=========00Medicaid