Provider Demographics
NPI:1699738039
Name:HOMETOWN CHIROPRACTIC LLC
Entity type:Organization
Organization Name:HOMETOWN CHIROPRACTIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:EBELSHEISER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:641-676-1400
Mailing Address - Street 1:120 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-2812
Mailing Address - Country:US
Mailing Address - Phone:641-676-1400
Mailing Address - Fax:641-676-1401
Practice Address - Street 1:120 N 1ST ST
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-2812
Practice Address - Country:US
Practice Address - Phone:641-676-1400
Practice Address - Fax:641-676-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06743111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0452748Medicaid
IA0479006Medicaid
IA38214OtherBLUE CROSS BLUE SHIEL ID
IA246032OtherMIDLANDS CHOICE ID
IA0452748Medicaid
IA246032OtherMIDLANDS CHOICE ID
IAI14751Medicare ID - Type UnspecifiedINDIVIDUAL ID