Provider Demographics
NPI:1831243286
Name:NOWACK, RONALD OTTO (DC)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:OTTO
Last Name:NOWACK
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:PO BOX 740
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739
Mailing Address - Country:US
Mailing Address - Phone:541-536-3693
Mailing Address - Fax:541-639-9448
Practice Address - Street 1:16410 3RD ST
Practice Address - Street 2:STE A
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739
Practice Address - Country:US
Practice Address - Phone:541-536-3693
Practice Address - Fax:541-636-9448
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR272735111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR107298Medicare ID - Type Unspecified