Provider Demographics
NPI:1144552068
Name:NORTHSIDE CHIROPRACTIC WELLNESS CENTER PLC
Entity type:Organization
Organization Name:NORTHSIDE CHIROPRACTIC WELLNESS CENTER PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRESTON
Authorized Official - Middle Name:H
Authorized Official - Last Name:TORNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:712-239-9095
Mailing Address - Street 1:PO BOX 2131
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-0131
Mailing Address - Country:US
Mailing Address - Phone:712-239-9095
Mailing Address - Fax:712-239-9123
Practice Address - Street 1:1551 INDIAN HILLS DR
Practice Address - Street 2:SUITE 8
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-1859
Practice Address - Country:US
Practice Address - Phone:712-239-9095
Practice Address - Fax:712-239-9123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06370111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI1884Medicare PIN