Provider Demographics
NPI:1124335286
Name:FRIDLEY CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:FRIDLEY CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-332-1769
Mailing Address - Street 1:1126 W PEARCE BLVD
Mailing Address - Street 2:STE 114
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-1053
Mailing Address - Country:US
Mailing Address - Phone:636-332-1769
Mailing Address - Fax:636-639-9235
Practice Address - Street 1:1126 W PEARCE BLVD
Practice Address - Street 2:STE 114
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-1053
Practice Address - Country:US
Practice Address - Phone:636-332-1769
Practice Address - Fax:636-639-9235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000161195261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty