Provider Demographics
NPI:1679971501
Name:AHMAD R. SPROUSE
Entity type:Organization
Organization Name:AHMAD R. SPROUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT CONTRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:RA'SHAD
Authorized Official - Last Name:SPROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:219-576-2313
Mailing Address - Street 1:1496 POPE CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-5302
Mailing Address - Country:US
Mailing Address - Phone:219-926-8522
Mailing Address - Fax:219-926-7513
Practice Address - Street 1:1496 POPE CT STE 3
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-5303
Practice Address - Country:US
Practice Address - Phone:219-926-8522
Practice Address - Fax:211-926-7513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN080002742A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty