Provider Demographics
NPI: | 1710487814 |
---|---|
Name: | JEFFERSONTOWN CHIROPRACTIC |
Entity Type: | Organization |
Organization Name: | JEFFERSONTOWN CHIROPRACTIC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MASSIMO |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BIANCO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 502-962-2277 |
Mailing Address - Street 1: | 10131 TAYLORSVILLE RD |
Mailing Address - Street 2: | |
Mailing Address - City: | LOUISVILLE |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 40299-3649 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 502-267-6444 |
Mailing Address - Fax: | 502-267-6445 |
Practice Address - Street 1: | 10131 TAYLORSVILLE RD |
Practice Address - Street 2: | |
Practice Address - City: | LOUISVILLE |
Practice Address - State: | KY |
Practice Address - Zip Code: | 40299-3649 |
Practice Address - Country: | US |
Practice Address - Phone: | 502-267-6444 |
Practice Address - Fax: | 502-267-6445 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-02-15 |
Last Update Date: | 2018-06-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KY | 5198 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Single Specialty |