Provider Demographics
NPI:1740536143
Name:CORNISH FAMILY CHIROPRACTIC LLC
Entity type:Organization
Organization Name:CORNISH FAMILY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNISH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:641-201-1028
Mailing Address - Street 1:1911 4TH ST SW
Mailing Address - Street 2:SUITE C
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-4601
Mailing Address - Country:US
Mailing Address - Phone:641-201-1028
Mailing Address - Fax:641-201-1033
Practice Address - Street 1:1911 4TH ST SW
Practice Address - Street 2:SUITE C
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-4601
Practice Address - Country:US
Practice Address - Phone:641-201-1028
Practice Address - Fax:641-201-1033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007195111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1548404007Medicaid