Provider Demographics
NPI:1487025656
Name:KINGSBURY CHIROPRACTIC LLC
Entity type:Organization
Organization Name:KINGSBURY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:775-781-4990
Mailing Address - Street 1:PO BOX 2183
Mailing Address - Street 2:
Mailing Address - City:STATELINE
Mailing Address - State:NV
Mailing Address - Zip Code:89449-2183
Mailing Address - Country:US
Mailing Address - Phone:775-580-7833
Mailing Address - Fax:
Practice Address - Street 1:276 KINGSBURY GRADE
Practice Address - Street 2:#1050
Practice Address - City:STATELINE
Practice Address - State:NV
Practice Address - Zip Code:89449-9804
Practice Address - Country:US
Practice Address - Phone:775-580-7833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV2015145727111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty