Provider Demographics
NPI:1942604145
Name:ABC CHIROPRACTIC PC
Entity Type:Organization
Organization Name:ABC CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:DEITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-730-7079
Mailing Address - Street 1:826 PARK DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-5336
Mailing Address - Country:US
Mailing Address - Phone:701-730-7079
Mailing Address - Fax:
Practice Address - Street 1:826 PARK DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5336
Practice Address - Country:US
Practice Address - Phone:701-730-7079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-16
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND682111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11334Medicaid
U76870Medicare UPIN
ND11334Medicaid