Provider Demographics
NPI:1194057885
Name:WATERVILLE CHIROPRACTIC CLINIC LLC
Entity type:Organization
Organization Name:WATERVILLE CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:W
Authorized Official - Last Name:SCHWANZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-878-8142
Mailing Address - Street 1:216 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-1463
Mailing Address - Country:US
Mailing Address - Phone:419-878-8142
Mailing Address - Fax:419-878-8143
Practice Address - Street 1:216 SOUTH ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-1463
Practice Address - Country:US
Practice Address - Phone:419-878-8142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1201111NT0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NT0100XChiropractic ProvidersChiropractorThermographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0632855Medicaid
SC0582532Medicare PIN
OH0632855Medicaid