Provider Demographics
NPI:1952496275
Name:COMMUNITY CHIROPRACTIC CLINIC, PC
Entity Type:Organization
Organization Name:COMMUNITY CHIROPRACTIC CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:219-836-2580
Mailing Address - Street 1:8000 CALUMET AVENUE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1218
Mailing Address - Country:US
Mailing Address - Phone:219-836-2580
Mailing Address - Fax:219-836-9366
Practice Address - Street 1:8000 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1227
Practice Address - Country:US
Practice Address - Phone:219-836-2580
Practice Address - Fax:219-836-9366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001591A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100147700AMedicaid