Provider Demographics
NPI:1740290907
Name:CCC PC
Entity type:Organization
Organization Name:CCC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:S
Authorized Official - Last Name:CONFER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:712-623-3526
Mailing Address - Street 1:404 NO 5TH ST
Mailing Address - Street 2:P.O. 407
Mailing Address - City:RED OAK
Mailing Address - State:IA
Mailing Address - Zip Code:51566-2323
Mailing Address - Country:US
Mailing Address - Phone:712-623-3526
Mailing Address - Fax:
Practice Address - Street 1:404 N 5TH ST
Practice Address - Street 2:P.O. 407
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566-2323
Practice Address - Country:US
Practice Address - Phone:712-623-3526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06364111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA231944OtherMIDLANDS CHOICE
IA24813OtherBCBS
IA484847348OtherSS#
IA484847348OtherSS#
IA=========OtherCURRENT TAX ID
IA42-1512921OtherOLD TAX ID NUMBER