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General NPI Number Information
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NPI Number | 1477736015
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Entity Type | Organization
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Legal Business Name | EDISS CHIROPRACTIC, INC
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Dates
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Enumeration Date | 12/05/2007
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Last Update Date | 01/20/2021
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Provider Practice Location Address
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Address Line | 1330 E RICHARDS ST
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City | DOUGLAS
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State | WY
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Zip | 82633-2951
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Country | US
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Telephone | 307-358-3147
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Fax | 307-358-3213
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Provider Business Mailing Address
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Address Line | 1330 E RICHARDS ST P.O. BOX 902
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City | DOUGLAS
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State | WY
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Zip | 82633-2951
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Country | US
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Telephone | 307-358-3147
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Fax | 307-358-3213
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHELE F. LISCO-EDISS
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Credential |
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Telephone | 307-358-5066
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 574
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License Number State | WY
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