Provider Demographics
NPI:1851669253
Name:CORYDON CHIROPRACTIC REHAB & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:CORYDON CHIROPRACTIC REHAB & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:MATHEW
Authorized Official - Last Name:STOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:812-738-8020
Mailing Address - Street 1:2127 EDSEL LN NW
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-2030
Mailing Address - Country:US
Mailing Address - Phone:812-738-8020
Mailing Address - Fax:812-738-1760
Practice Address - Street 1:2127 EDSEL LN NW
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2030
Practice Address - Country:US
Practice Address - Phone:812-738-8020
Practice Address - Fax:812-738-1760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001813A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200221940AMedicaid
IN151150Medicare PIN
INU80426Medicare UPIN