OrganizationActiveAccepts Medicare
Countryside Clinic of Chiropractic, LLC
NPI 1063837367 · Chiropractor · Lebanon, OH
Enrolled with Medicare as Part B Supplier - Clinic/Group Practice · source: CMS PECOS Public Provider Enrollment (2026.04.01)
Provider details
- NPI number
- 1063837367
- Entity type
- Organization
- Primary specialty
- ChiropractorChiropractic Providers
- Organization subpart
- No
- Authorized official
- Tony Dejtiranukul, Owner(314) 496-6030
- License
- 4008 (OH)
Specialties & taxonomies
Chiropractic Providers
Profile Score
Detailed profile(76/100 index)
A profile completeness & documented-activity index — NOT a quality, outcomes, or patient-satisfaction rating.
- Registry tenure38% of score
12 yrs in NPPES registry
- Profile completeness38% of score
100% of core fields populated
- Practice footprint23% of score
1 documented practice location
Signals a provider has no public data for (e.g. Medicare claims) are left out of the score entirely — never counted as zero — so providers without that data are not penalized. See the full formula and weights in our methodology.
Practice location
990 Belvedere Dr Ste B
Lebanon, OH 45036-1193
Phone: (513) 836-8844
Fax: (513) 836-8845
Street-level locationGet directions
Mailing address
990 Belvedere Dr Ste B
Lebanon, OH 45036-1193
Registry dates
- Enumerated
- 2014-02-23
- Last updated
- 2019-11-26
Source: CMS NPPES Data Dissemination (June 2026). NPI Central is not affiliated with CMS. Data is provided as-is from the public registry.