Healthcare Provider Details

I. General information

NPI: 1710124631
Provider Name (Legal Business Name): 96TH STREET CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 04/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9598 ALLISONVILLE ROAD
INDIANAPOLIS IN
46250
US

IV. Provider business mailing address

PO BOX 501608
INDIANAPOLIS IN
46250
US

V. Phone/Fax

Practice location:
  • Phone: 317-598-9696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08001549A
License Number StateIN

VIII. Authorized Official

Name: MICHAEL FLYNN
Title or Position: CHIROPRACTOR/ OWNER
Credential: D.C.
Phone: 317-598-9696