Provider Demographics
NPI:1427355817
Name:WYOMING CHIROPRACTIC CLINIC LLC
Entity type:Organization
Organization Name:WYOMING CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-659-1667
Mailing Address - Street 1:306 11TH ST
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-1404
Mailing Address - Country:US
Mailing Address - Phone:563-659-1667
Mailing Address - Fax:563-221-9218
Practice Address - Street 1:112 E WEBSTER ST
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:IA
Practice Address - Zip Code:52362-7775
Practice Address - Country:US
Practice Address - Phone:563-659-5582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty