Healthcare Provider Details

I. General information

NPI: 1508248642
Provider Name (Legal Business Name): OPTIMAL CHIROPRACTIC FAMILY SPORTS REHAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 10/21/2023
Certification Date: 10/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11420 BROADWAY
CROWN POINT IN
46307-7106
US

IV. Provider business mailing address

11420 BROADWAY
CROWN POINT IN
46307-7106
US

V. Phone/Fax

Practice location:
  • Phone: 219-661-8680
  • Fax: 219-661-8280
Mailing address:
  • Phone: 219-661-8680
  • Fax: 219-661-8280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. ASHLEY RENEE NELSON
Title or Position: OWNER/PHYSICIAN
Credential: DC, FNP
Phone: 219-661-8680