Provider Demographics
NPI:1669784666
Name:BITTERROOT VALLEY SPINAL CARE PLLC
Entity type:Organization
Organization Name:BITTERROOT VALLEY SPINAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WANDERAAS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-399-2588
Mailing Address - Street 1:289 RODEO DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FLORENCE
Mailing Address - State:MT
Mailing Address - Zip Code:59833-6826
Mailing Address - Country:US
Mailing Address - Phone:636-399-2588
Mailing Address - Fax:
Practice Address - Street 1:289 RODEO DR
Practice Address - Street 2:SUITE 3
Practice Address - City:FLORENCE
Practice Address - State:MT
Practice Address - Zip Code:59833-6826
Practice Address - Country:US
Practice Address - Phone:636-399-2588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-07
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty