Provider Demographics
NPI:1780697136
Name:HOOSIER FAMILY CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:HOOSIER FAMILY CHIROPRACTIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUGH-HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:812-336-7552
Mailing Address - Street 1:3901 HAGAN ST STE C
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8516
Mailing Address - Country:US
Mailing Address - Phone:812-336-7552
Mailing Address - Fax:812-336-7556
Practice Address - Street 1:3901 HAGAN ST STE C
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8516
Practice Address - Country:US
Practice Address - Phone:812-336-7556
Practice Address - Fax:812-336-7556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001999A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200341440Medicaid
INU88306Medicare UPIN
IN217750Medicare PIN