Healthcare Provider Details

I. General information

NPI: 1871784363
Provider Name (Legal Business Name): WEST SIDE CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 S BERKLEY RD
KOKOMO IN
46901-5110
US

IV. Provider business mailing address

808 S BERKLEY RD
KOKOMO IN
46901-5110
US

V. Phone/Fax

Practice location:
  • Phone: 765-457-0099
  • Fax: 765-457-0299
Mailing address:
  • Phone: 765-457-0099
  • Fax: 765-457-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08001997A
License Number StateIN

VIII. Authorized Official

Name: TRISHA ANN OLIBA
Title or Position: OWNER
Credential: D.C.
Phone: 765-457-0099