Provider Demographics
NPI:1396715694
Name:WONDRA FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:WONDRA FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:L
Authorized Official - Last Name:WONDRA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:319-372-7898
Mailing Address - Street 1:724 AVE G
Mailing Address - Street 2:
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-2927
Mailing Address - Country:US
Mailing Address - Phone:319-372-7898
Mailing Address - Fax:319-372-5232
Practice Address - Street 1:724 AVE G
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-2927
Practice Address - Country:US
Practice Address - Phone:319-372-7898
Practice Address - Fax:319-372-5232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
IA06602111N00000X
IA06523111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
19789OtherBLUE CROSS BS WELLMARK
525812OtherIOWA HEALTH SOLUTIONS
I12117Medicare ID - Type Unspecified