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General NPI Number Information
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NPI Number | 1780814889
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Entity Type | Organization
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Legal Business Name | ERICKSON CHIROPRACTIC L.L.C.
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Dates
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Enumeration Date | 07/23/2009
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Last Update Date | 07/23/2009
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Provider Practice Location Address
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Address Line | 32 EAST 4TH AVENUE
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City | AFTON
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State | WY
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Zip | 83110
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Country | US
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Telephone | 307-885-9414
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Fax | 307-885-9413
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Provider Business Mailing Address
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Address Line | PO BOX 1676
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City | AFTON
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State | WY
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Zip | 83110
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Country | US
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Telephone | 307-885-9414
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Fax | 307-885-9413
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Authorized Official
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Title or Position | OWNER/DOCTOR OF CHIROPRACTIC
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Name | DR. CLINT R ERICKSON
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Credential | D.C.
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Telephone | 307-885-9414
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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 | 694
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License Number State | WY
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