Provider Demographics
NPI:1740264746
Name:TRI-STATE CHIROPRACTIC CLINIC, INC.
Entity type:Organization
Organization Name:TRI-STATE CHIROPRACTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:E
Authorized Official - Last Name:LUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:402-494-5173
Mailing Address - Street 1:3900 DAKOTA AVE
Mailing Address - Street 2:SUITE #6
Mailing Address - City:SOUTH SIOUX CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68776-3696
Mailing Address - Country:US
Mailing Address - Phone:402-494-5173
Mailing Address - Fax:402-494-5151
Practice Address - Street 1:3900 DAKOTA AVE
Practice Address - Street 2:SUITE #6
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-3696
Practice Address - Country:US
Practice Address - Phone:402-494-5173
Practice Address - Fax:402-494-5151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0548594Medicaid