Provider Demographics
NPI:1689743478
Name:MIDWAY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:MIDWAY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-323-1551
Mailing Address - Street 1:1900 STATE ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-5195
Mailing Address - Country:US
Mailing Address - Phone:563-323-1551
Mailing Address - Fax:
Practice Address - Street 1:1900 STATE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-5195
Practice Address - Country:US
Practice Address - Phone:563-323-1551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06817111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA39899OtherBLUE CROSS BLUE SHIELD