Provider Demographics
NPI:1962791863
Name:WAALE CHIROPRACTIC CLINIC PLLC
Entity type:Organization
Organization Name:WAALE CHIROPRACTIC CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:WAALE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-365-0401
Mailing Address - Street 1:417 MAIN AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1956
Mailing Address - Country:US
Mailing Address - Phone:701-365-0401
Mailing Address - Fax:701-365-0402
Practice Address - Street 1:417 MAIN AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1956
Practice Address - Country:US
Practice Address - Phone:701-365-0401
Practice Address - Fax:701-365-0402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND474111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty