Provider Demographics
NPI:1306253786
Name:DAVIS CHIROPRACTIC
Entity type:Organization
Organization Name:DAVIS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:G
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-347-4006
Mailing Address - Street 1:722 FRONT ST
Mailing Address - Street 2:PO BOX 518
Mailing Address - City:CASSELTON
Mailing Address - State:ND
Mailing Address - Zip Code:58012-3302
Mailing Address - Country:US
Mailing Address - Phone:701-347-4006
Mailing Address - Fax:701-347-4247
Practice Address - Street 1:772 FRONT STREET
Practice Address - Street 2:BOX 518
Practice Address - City:CASSELTON
Practice Address - State:ND
Practice Address - Zip Code:58012-0518
Practice Address - Country:US
Practice Address - Phone:701-347-4006
Practice Address - Fax:701-347-4247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND413261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13919Medicaid
ND13919Medicaid