Provider Demographics
NPI:1679662191
Name:CLOCKTOWER CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:CLOCKTOWER CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:402-397-8980
Mailing Address - Street 1:633 N 98TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2342
Mailing Address - Country:US
Mailing Address - Phone:402-397-8980
Mailing Address - Fax:402-397-8977
Practice Address - Street 1:633 N 98TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2342
Practice Address - Country:US
Practice Address - Phone:402-397-8980
Practice Address - Fax:402-397-8977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1404111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025288200Medicaid
NE10025288200Medicaid
NE279280Medicare ID - Type Unspecified