Doctor First Name *
Doctor Last Name *
Cell Phone Number
Degree * DC LMT MD PT RN
NPI Number
Tax ID Number
Malpractice Insurance Carrier
Premise Insurance Carrier
Clinic Name *
Clinic Address *
City *
State * AL AK AP AR AZ AS CA CT CO DE DC FM FL GA HI ID IL IN IA KS KY LA MP MH ME MN MA MD MS MT MO MI NE NV NH NJ NM NY NC ND OR OH OK PA PR RI SC SD TN TX UT VA VT VI WA WV WI WY
Zip *
Clinic Phone *
Clinic Fax *
Doctor Email Address *
Staff Person First Name
Staff/Clinic Contact Email
Number of Clinic Locations *
Number of Providers *
State Association Supported * Alabama State Chiropractic Association Arkansas Chiropractic Association Alaska Chiropractic Society Arizona Association of Chiropractic Arizona Chiropractic Society California Chiropractic Association Chiropractic Society of Texas Colorado Chiropractic Association Connecticut Chiropractic Council Connecticut Chiropractic Association Delaware Chiropractic Society Florida Chiropractic Association Georgia Chiropractic Association Georgia Council of Chiropractic Iowa Chiropractic Society Hawaii State Chiropractic Association Idaho Association of Chiropractic Physicians Illinois Chiropractic Society International Chiropractors Association of Indiana Indiana State Chiropractic Association Kansas Chiropractic Association Kentucky Association of Chiropractors Kentucky Chiropractic Association, INC Chiropractic Association of Louisiana Massachusetts Chiropractic Society Maryland Chiropractic Association Maine Chiropractic Association Michigan Association of Chiropractors Minnesota Chiropractic Association Missouri State Chiropractors Association Mississippi Chiropractic Association Montana Chiropractic Association North Carolina Chiropractic Association North Dakota Chiropractic Association Nebraska Chiropractic Physicians Association New Hampshire State Chiropractic Society New Hampshire Chiropractic Association Association of New Jersey Chiropractors New Mexico Chiropractic Association Nevada Chiropractic Association New York Chiropractic Council New York State Chiropractic Association Ohio State Chiropractic Association Oklahoma Chiropractors' Association Unified Chiropractic Association of Oklahoma Oklahoma State Chiropractic Independent Physicians Assoc Oregon Chiropractic Association Chiropractic Fellowship of Pennsylvania Pennsylvania Chiropractic Association Chiropractic Society of Rhode Island South Carolina Chiropractic Association South Dakota Chiropractors Association Tennessee Chiropractic Association Texas Chiropractic Association Utah Chiropractic Physicians Association Unified Virginia Chiropractic Association Chiropractic Society of Wisconsin Vermont Chiropractic Association Washington State Chiropractic Association West Virginia Chiropractic Society Wisconsin Chiropractic Association Wyoming Chiropractic Association
Clinic Website
Average Number of New Patients Per Month (All Locations) *
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