Evansdale Chiropractic Clinic, PLC
Organization Active NPI Chiropractor · Evansdale, IA
NPI 1477581478 · NPPES record last updated Feb 3, 2015
Key facts
- NPI
- 1477581478
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Chiropractor 111N00000X
- License
- A5374 (IA)
- Legal business name
- EVANSDALE CHIROPRACTIC CLINIC, PLC
- Practice address
- 209 S Evans Rd
Evansdale, IA 50707-1121 - Phone
- (319) 234-4872
- Fax
- (319) 236-0670
- NPI assigned
- Jun 29, 2006
- Organization subpart
- No
Authorized official
- Name
- Mr. Duane A Widen, D.C./DI BCN
- Title
- Owner
- Phone
- (319) 234-4872
Practitioners 5
-
Duane Alan Widen, DC, DIBCN
-
Kyle Borrett, DC
-
Joseph Edward Knebel, D.C.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040323001022 | IA | Part B Supplier - Clinic/Group Practice | 9133010747 |
Receives reassigned benefits from 2 practitioners Practice locations: Evansdale, IA |
National Provider Directory
Locations
209 S Evans Rd
Evansdale, IA 50707
Phone (319) 234-4872
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Chiropractor |
111N00000X | A5374 | IA | Yes |
Addresses
Primary practice location
209 S Evans Rd
Evansdale, IA 50707-1121
Mailing address
209 S Evans Rd
Evansdale, IA 50707-1121
Phone (319) 234-4872
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0287854 | Medicaid | IA |
Other providers in Evansdale, IA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 3, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.