Provider Demographics
NPI:1740906148
Name:IMPACT CHIROPRACTIC CENTER, PLLC
Entity type:Organization
Organization Name:IMPACT CHIROPRACTIC CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:NATHAN
Authorized Official - Last Name:JAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-230-1825
Mailing Address - Street 1:250 25TH ST S STE B
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6817
Mailing Address - Country:US
Mailing Address - Phone:701-230-1825
Mailing Address - Fax:
Practice Address - Street 1:250 25TH ST S STE B
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6817
Practice Address - Country:US
Practice Address - Phone:701-230-1825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty