Provider Demographics
NPI:1851664270
Name:COMMUNITY CHIROPRACTIC-PORTAGE, P.C.
Entity Type:Organization
Organization Name:COMMUNITY CHIROPRACTIC-PORTAGE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:STITT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:219-763-7970
Mailing Address - Street 1:6325 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3801
Mailing Address - Country:US
Mailing Address - Phone:219-763-7970
Mailing Address - Fax:219-762-5338
Practice Address - Street 1:6325 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3801
Practice Address - Country:US
Practice Address - Phone:219-763-7970
Practice Address - Fax:219-762-5338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002577A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty