Provider Demographics
NPI:1760855324
Name:STEVENS CHIROPRACTIC CENTER, PC
Entity Type:Organization
Organization Name:STEVENS CHIROPRACTIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:260-665-9479
Mailing Address - Street 1:903 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-1167
Mailing Address - Country:US
Mailing Address - Phone:260-665-9479
Mailing Address - Fax:260-665-9470
Practice Address - Street 1:903 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-1167
Practice Address - Country:US
Practice Address - Phone:260-665-9479
Practice Address - Fax:260-665-9470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002549A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201277400Medicaid