Provider Demographics
NPI:1336330364
Name:DUPONT FAMILY CHIROPRACTIC PC
Entity Type:Organization
Organization Name:DUPONT FAMILY CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-490-3400
Mailing Address - Street 1:10315 DAWSONS CREEK BLVD
Mailing Address - Street 2:STE I
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1912
Mailing Address - Country:US
Mailing Address - Phone:260-490-3400
Mailing Address - Fax:260-489-5930
Practice Address - Street 1:10315 DAWSONS CREEK BLVD
Practice Address - Street 2:STE I
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1912
Practice Address - Country:US
Practice Address - Phone:260-490-3400
Practice Address - Fax:260-489-5930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2010-03-30
Deactivation Date:2008-03-25
Deactivation Code:
Reactivation Date:2010-03-30
Provider Licenses
StateLicense IDTaxonomies
IN08001604A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU58728Medicare UPIN