Provider Demographics
NPI:1063780104
Name:EDWARD A. MADRID, DC, PC
Entity type:Organization
Organization Name:EDWARD A. MADRID, DC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MADRID
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-628-4622
Mailing Address - Street 1:104 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MT
Mailing Address - Zip Code:59044-3030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 E 1ST ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MT
Practice Address - Zip Code:59044-3030
Practice Address - Country:US
Practice Address - Phone:406-628-4622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1204111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1043385479OtherPTAN