Provider Demographics
NPI:1104066646
Name:CHIROPRACTIC CLINIC OF THREE FORKS
Entity type:Organization
Organization Name:CHIROPRACTIC CLINIC OF THREE FORKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:FUNKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-285-6935
Mailing Address - Street 1:PO BOX 1307
Mailing Address - Street 2:217 MAIN ST
Mailing Address - City:THREE FORKS
Mailing Address - State:MT
Mailing Address - Zip Code:59752-1307
Mailing Address - Country:US
Mailing Address - Phone:406-285-6935
Mailing Address - Fax:406-285-6935
Practice Address - Street 1:217 MAIN ST
Practice Address - Street 2:
Practice Address - City:THREE FORKS
Practice Address - State:MT
Practice Address - Zip Code:59752-1307
Practice Address - Country:US
Practice Address - Phone:406-285-6935
Practice Address - Fax:406-285-6935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT583111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000042163OtherBLUE CROSS BLUE SHIELD