Provider Demographics
NPI:1366550915
Name:MILLENNIUM CHIROPRACTIC PC
Entity type:Organization
Organization Name:MILLENNIUM CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-246-5954
Mailing Address - Street 1:813 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-2301
Mailing Address - Country:US
Mailing Address - Phone:712-246-5954
Mailing Address - Fax:712-246-3269
Practice Address - Street 1:813 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-2301
Practice Address - Country:US
Practice Address - Phone:712-246-5954
Practice Address - Fax:712-246-3269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0196113Medicaid
IA0196113Medicaid