Healthcare Provider Details

I. General information

NPI: 1497767115
Provider Name (Legal Business Name): YELLOWSTONE CHIROPRACTIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 E MAIN ST
LOVELL WY
82431-2101
US

IV. Provider business mailing address

223 E MAIN ST
LOVELL WY
82431-2101
US

V. Phone/Fax

Practice location:
  • Phone: 307-548-9338
  • Fax: 307-548-9335
Mailing address:
  • Phone: 307-548-9338
  • Fax: 307-548-9335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number615
License Number StateWY

VIII. Authorized Official

Name: DR. ROSS B FULLER
Title or Position: PRESIDENT
Credential: DC
Phone: 307-548-9338