Provider Demographics
NPI:1770030520
Name:WIDHELM CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:WIDHELM CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WIDHELM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-902-9067
Mailing Address - Street 1:1520 N COMMERCE ST
Mailing Address - Street 2:STE C
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1861
Mailing Address - Country:US
Mailing Address - Phone:402-902-9067
Mailing Address - Fax:
Practice Address - Street 1:1520 N COMMERCE ST
Practice Address - Street 2:STE C
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1861
Practice Address - Country:US
Practice Address - Phone:402-902-9067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE767111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NET40192Medicare UPIN