Healthcare Provider Details

I. General information

NPI: 1013290030
Provider Name (Legal Business Name): FUNCTIONAL CHIROPRACTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 W WALNUT ST
OGDEN IA
50212-3048
US

IV. Provider business mailing address

329 W WALNUT ST
OGDEN IA
50212-3048
US

V. Phone/Fax

Practice location:
  • Phone: 515-232-9075
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number04631
License Number StateIA

VIII. Authorized Official

Name: RICHARD A ELBERT
Title or Position: OWNER
Credential: D.C.
Phone: 515-232-9075