=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417394024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INBODY CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2013
-----------------------------------------------------
Last Update Date | 10/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3220 DODGE ST
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52003-5246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-583-7700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3220 DODGE ST
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52003-5246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-583-7700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DOUG CHRISTENSEN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 563-583-7700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 074898
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------