Provider Demographics
NPI:1750659819
Name:SPIRIT LAKE CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:SPIRIT LAKE CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:FIALA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:712-336-3304
Mailing Address - Street 1:609 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-1502
Mailing Address - Country:US
Mailing Address - Phone:712-336-3304
Mailing Address - Fax:712-336-4619
Practice Address - Street 1:609 18TH ST
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1502
Practice Address - Country:US
Practice Address - Phone:712-336-3304
Practice Address - Fax:712-336-4619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04949261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1015321Medicaid
IA56388OtherWELLMARK
IAT92979Medicare UPIN
IA18295Medicare PIN