Provider Demographics
NPI:1952442782
Name:KOSTELECKY CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:KOSTELECKY CHIROPRACTIC CLINIC INC
Other - Org Name:CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KOSTELECKY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-225-3536
Mailing Address - Street 1:383 15TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3017
Mailing Address - Country:US
Mailing Address - Phone:701-225-3536
Mailing Address - Fax:
Practice Address - Street 1:383 15TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3017
Practice Address - Country:US
Practice Address - Phone:701-225-3536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND555111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDKOS 18901OtherBLUE CROSS BLUE SHIELD
ND17849Medicaid
NDU45389Medicare UPIN
NDKOS 18901OtherBLUE CROSS BLUE SHIELD