Provider Demographics
NPI:1962751669
Name:WHITE MOUNTAIN CHIROPRACTIC INC.
Entity type:Organization
Organization Name:WHITE MOUNTAIN CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:KLINEKOLE
Authorized Official - Suffix:III
Authorized Official - Credentials:DC, DACNB
Authorized Official - Phone:575-257-7970
Mailing Address - Street 1:500 MECHEM DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6949
Mailing Address - Country:US
Mailing Address - Phone:575-257-7970
Mailing Address - Fax:575-257-7970
Practice Address - Street 1:500 MECHEM DR
Practice Address - Street 2:SUITE C
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6949
Practice Address - Country:US
Practice Address - Phone:575-257-7970
Practice Address - Fax:575-257-7970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1375111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM585929590OtherMEDICARE PTAN
NML4208Medicaid