Provider Demographics
NPI:1962467522
Name:DIRKS CHIROPRACTIC CENTER PC
Entity Type:Organization
Organization Name:DIRKS CHIROPRACTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES SEC TREAS
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:DIRKS
Authorized Official - Suffix:
Authorized Official - Credentials:MS DC
Authorized Official - Phone:712-328-1625
Mailing Address - Street 1:1601 MCPHERSON AVE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503
Mailing Address - Country:US
Mailing Address - Phone:712-328-1625
Mailing Address - Fax:712-388-0389
Practice Address - Street 1:1601 MCPHERSON AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503
Practice Address - Country:US
Practice Address - Phone:712-328-1625
Practice Address - Fax:712-388-0389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04944111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0208868Medicaid
IA20886OtherBCBS
22690OtherMIDLANDS CHOICE PIN
35005194OtherMEDICARE UHC
3602OtherUPREHS
IA20886Medicare ID - Type Unspecified