Provider Demographics
NPI:1871523555
Name:BOONE FAMILY CHIROPRACTIC P.C.
Entity type:Organization
Organization Name:BOONE FAMILY CHIROPRACTIC P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:S
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:605-766-2225
Mailing Address - Street 1:PO BOX 203
Mailing Address - Street 2:
Mailing Address - City:VIBORG
Mailing Address - State:SD
Mailing Address - Zip Code:57070-0203
Mailing Address - Country:US
Mailing Address - Phone:605-766-2225
Mailing Address - Fax:605-766-3305
Practice Address - Street 1:102 N MAIN ST.
Practice Address - Street 2:
Practice Address - City:VIBORG
Practice Address - State:SD
Practice Address - Zip Code:57070-0203
Practice Address - Country:US
Practice Address - Phone:605-766-2225
Practice Address - Fax:605-766-3305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
S101069Medicare PIN