Provider Demographics
NPI:1255721189
Name:VITALITY CHIRO PC
Entity type:Organization
Organization Name:VITALITY CHIRO PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:FANNING
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS
Authorized Official - Phone:308-284-0838
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:OGALLALA
Mailing Address - State:NE
Mailing Address - Zip Code:69153-0096
Mailing Address - Country:US
Mailing Address - Phone:308-284-0838
Mailing Address - Fax:308-284-0848
Practice Address - Street 1:214 E STAPLES ST
Practice Address - Street 2:
Practice Address - City:ARTHUR
Practice Address - State:NE
Practice Address - Zip Code:69121-8410
Practice Address - Country:US
Practice Address - Phone:308-284-0838
Practice Address - Fax:308-284-0848
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VITALITY CHIRO PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1567111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026132200Medicaid