Provider Demographics
NPI:1013658566
Name:CLEARWATER CHIROPRACTIC PC
Entity Type:Organization
Organization Name:CLEARWATER CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARICELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-550-3493
Mailing Address - Street 1:2330 SOUTH HIGGINS AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6923
Mailing Address - Country:US
Mailing Address - Phone:406-728-0330
Mailing Address - Fax:406-728-0330
Practice Address - Street 1:2330 SOUTH HIGGINS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6923
Practice Address - Country:US
Practice Address - Phone:406-728-0330
Practice Address - Fax:406-728-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty