Healthcare Provider Details

I. General information

NPI: 1104002013
Provider Name (Legal Business Name): KEOKUK CHIROPRACTIC & SPORTS INJURY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 MAIN ST
KEOKUK IA
52632-4655
US

IV. Provider business mailing address

924 MAIN ST
KEOKUK IA
52632-4655
US

V. Phone/Fax

Practice location:
  • Phone: 319-524-0905
  • Fax:
Mailing address:
  • Phone: 319-524-0905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DENNIS E. WOLTER
Title or Position: PRESIDENT
Credential:
Phone: 319-524-0905