Provider Demographics
NPI:1891877239
Name:CENTRAL AVENUE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:CENTRAL AVENUE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SAYLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-845-0709
Mailing Address - Street 1:323 CENTRAL AVE N
Mailing Address - Street 2:SUITE 202
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-2915
Mailing Address - Country:US
Mailing Address - Phone:701-845-0709
Mailing Address - Fax:701-845-5988
Practice Address - Street 1:323 CENTRAL AVENUE NORTH
Practice Address - Street 2:SUITE 202
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072
Practice Address - Country:US
Practice Address - Phone:701-845-0709
Practice Address - Fax:701-845-5988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13050Medicaid
ND01049001OtherBLUE CROSS BLUE SHIELD
ND13050Medicaid