Provider Demographics
NPI:1730360777
Name:COLDWATER CHIROPRACTIC CLINIC INC.
Entity type:Organization
Organization Name:COLDWATER CHIROPRACTIC CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DERON
Authorized Official - Middle Name:
Authorized Official - Last Name:BLASINGAME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-678-7746
Mailing Address - Street 1:201 N MILL ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:OH
Mailing Address - Zip Code:45828-1219
Mailing Address - Country:US
Mailing Address - Phone:419-678-7746
Mailing Address - Fax:419-678-1327
Practice Address - Street 1:201 N MILL ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:OH
Practice Address - Zip Code:45828-1219
Practice Address - Country:US
Practice Address - Phone:419-678-7746
Practice Address - Fax:419-678-1327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2441111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0838381Medicare PIN