=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992025340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VILLAGE CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2010
-----------------------------------------------------
Last Update Date | 09/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10536 COLDWATER RD
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-1268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-637-9900
-----------------------------------------------------
Fax | 260-637-9099
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10536 COLDWATER RD
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-1268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-637-9900
-----------------------------------------------------
Fax | 260-637-9099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. HEATHER MARIE GICK
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 260-637-9900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 08002225A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------