Provider Demographics
NPI:1447500129
Name:AMOSSON CHIROPRACTIC PC
Entity type:Organization
Organization Name:AMOSSON CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:AMOSSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-236-2737
Mailing Address - Street 1:3510 KIMBALL AVE
Mailing Address - Street 2:STE. B
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3510 KIMBALL AVE
Practice Address - Street 2:STE. B
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5760
Practice Address - Country:US
Practice Address - Phone:319-236-2737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA06072111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1165753Medicaid
I1113Medicare PIN