Provider Demographics
NPI:1821030297
Name:STREETSBORO CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:STREETSBORO CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHEAT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:330-626-5561
Mailing Address - Street 1:PO BOX 2067
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-0067
Mailing Address - Country:US
Mailing Address - Phone:330-626-5561
Mailing Address - Fax:330-626-9219
Practice Address - Street 1:9125 STATE ROUTE 14
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-5629
Practice Address - Country:US
Practice Address - Phone:330-626-5561
Practice Address - Fax:330-626-9219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH907111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0473232Medicaid
T47398Medicare UPIN
9272731Medicare ID - Type UnspecifiedMEDICARE ID NUMBER