Provider Demographics
NPI:1790973972
Name:LAUREL STREET CHIROPRACTIC & SPA PC
Entity Type:Organization
Organization Name:LAUREL STREET CHIROPRACTIC & SPA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:THROCKMORTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC DABCI
Authorized Official - Phone:907-248-2848
Mailing Address - Street 1:4119 LAUREL STREET
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-248-2848
Mailing Address - Fax:
Practice Address - Street 1:4119 LAUREL STREET
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-248-2848
Practice Address - Fax:907-258-6610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA219111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCH0219Medicaid
AKCH0219Medicaid