Provider Demographics
NPI:1770904377
Name:CHRISTOPHERSEN, CALVIN RAY (DC)
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:RAY
Last Name:CHRISTOPHERSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 ELY ST
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:IA
Mailing Address - Zip Code:51579-1204
Mailing Address - Country:US
Mailing Address - Phone:712-647-3444
Mailing Address - Fax:
Practice Address - Street 1:410 ELY ST
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:IA
Practice Address - Zip Code:51579-1204
Practice Address - Country:US
Practice Address - Phone:712-647-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-27
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAAPPLIED FOR111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor