Provider Demographics
NPI:1912320540
Name:ELLENDALE CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:ELLENDALE CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:KENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-349-4727
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:ELLENDALE
Mailing Address - State:ND
Mailing Address - Zip Code:58436-0159
Mailing Address - Country:US
Mailing Address - Phone:701-349-4727
Mailing Address - Fax:701-349-3033
Practice Address - Street 1:305 1ST AVE S
Practice Address - Street 2:
Practice Address - City:ELLENDALE
Practice Address - State:ND
Practice Address - Zip Code:58436-7108
Practice Address - Country:US
Practice Address - Phone:701-349-4727
Practice Address - Fax:701-349-3033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND434111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND015054Medicaid
SD7602400Medicaid
SD7602400Medicaid