Provider Demographics
NPI:1932190584
Name:SPORTS & FAMILY CHIROPRACTIC LTD
Entity Type:Organization
Organization Name:SPORTS & FAMILY CHIROPRACTIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:HEIM
Authorized Official - Last Name:SCHALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-244-1365
Mailing Address - Street 1:65 S MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WATERBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05676-1550
Mailing Address - Country:US
Mailing Address - Phone:802-244-1365
Mailing Address - Fax:802-244-0840
Practice Address - Street 1:65 S MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:WATERBURY
Practice Address - State:VT
Practice Address - Zip Code:05676-1550
Practice Address - Country:US
Practice Address - Phone:802-244-1365
Practice Address - Fax:802-244-0840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0060001123111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN3711Medicaid
VT68628OtherBLUE CROSS BLUE SHIELD
VT67513OtherCIGNA
VT67513OtherCIGNA