Provider Demographics
NPI:1932257300
Name:JONATHAN CHIROPRACTIC PC
Entity Type:Organization
Organization Name:JONATHAN CHIROPRACTIC PC
Other - Org Name:WELLNESS DIMENSIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:DEITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:7012-222-8322
Mailing Address - Street 1:1051 E INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0551
Mailing Address - Country:US
Mailing Address - Phone:701-222-8322
Mailing Address - Fax:701-222-8397
Practice Address - Street 1:1051 E INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0551
Practice Address - Country:US
Practice Address - Phone:701-222-8322
Practice Address - Fax:701-222-8397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND682111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDDE7888OtherRAILROAD MEDICARE
ND1818OtherBLUE CROSS BLUE SHIELD
ND13403Medicaid
NDU76870Medicare UPIN
ND13403Medicaid