Provider Demographics
NPI:1770796476
Name:CHIROPRACTIC LOUISVILLE PLLC
Entity type:Organization
Organization Name:CHIROPRACTIC LOUISVILLE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:502-891-0333
Mailing Address - Street 1:152 THIERMAN LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-5010
Mailing Address - Country:US
Mailing Address - Phone:502-891-0333
Mailing Address - Fax:502-721-0086
Practice Address - Street 1:152 THIERMAN LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5010
Practice Address - Country:US
Practice Address - Phone:502-891-0333
Practice Address - Fax:502-721-0086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-04-03
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-09-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYV08554Medicare UPIN
KY6104802Medicare ID - Type Unspecified