How to start a chiropractic practice

The path from chiropractic student to practice owner, in the order it happens: national boards, the state license, NPI, Medicare and insurance credentialing, setup and the first patients, with every agency named. The finding that changes the business plan: federal rules do not let chiropractors opt out of Medicare, so even a cash-only office has to decide how it will handle patients on Medicare before it opens.

By Niomi AscotUpdated October 3, 202616 min read

License: Required in every state, issued by the state chiropractic board after a CCE-accredited D.C. degree
National boards: NBCE Parts I to IV in all four states covered here; physiotherapy too in California, Texas and Florida, not New York
Board fees: $710 each for Parts I, II and III, $1,585 for Part IV, $450 for physiotherapy (NBCE, as of October 2026)
Medicare: Chiropractors cannot opt out. Part B pays only for adjustments of the spine to correct a subluxation.
Credentialing order: NPI first, then PECOS for Medicare and a CAQH profile for commercial plans
Workforce: About 70,000 chiropractors (ACA); 57,200 employed in 2024 with a $79,200 median wage in 2025 (BLS via O*NET)

What a chiropractic practice is, and the ways into ownership

The American Chiropractic Association puts the profession at about 70,000 US chiropractors, all “required to pass a series of four national board exams and become state licensed”, and estimates they treat “more than 35 million Americans (adults and children) annually.”

The NBCE’s Practice Analysis of Chiropractic 2025 surveyed 3,876 chiropractors from June to August 2024, letting them pick more than one answer:

Where they practice. A single-doctor office for 49%, a multi-doctor office for 36%, a multidisciplinary health care facility for 12%. Franchise and concierge practices came in at 3% each, mobile practice at 1%.
What role they hold. Sole proprietor for 55%, associate or employee for 23%, business partner for 11%, contractor for 5%.
Who pays them. Cash or private pay was named by 41%, private insurance by 37%, and Medicare and personal injury insurance by 9% apiece.

Looking toward 2034, the NBCE expects sole proprietors to stay the largest group and says “mobile, franchise, and concierge care, will likely continue to increase.”

Most owners arrive by one of three routes, and in our experience the choice turns on cash and patience more than on clinical skill:

Associate first. Learn scheduling, billing and the front desk in someone else’s practice, then open or buy.
Open from nothing. The lowest purchase cost and the slowest revenue, since credentialing, the patient list and the online profile all begin at zero.
Buy a practice. Patients and cash flow from the first week, at a price. The SBA’s 7(a) program lists “changes of ownership (complete or partial)” as an eligible use, with a $5 million maximum loan.

Cash, insurance and personal injury practices also credential, bill and get paid on very different clocks, so choose the payer mix as deliberately as the route.

The outlook for chiropractors

Bureau of Labor Statistics data for occupation 29-1011.00, published on O*NET, shows 57,200 people employed as chiropractors in 2024 and a 2025 median wage of $38.08 an hour, or $79,200 a year. Growth from 2024 to 2034 is projected as “much faster than average (7% or higher)”, with 2,800 projected job openings listed for the period.

The ACA counts about 11,000 students in 19 accredited programs and “about 2,800 chiropractors entering the workforce every year.” On the patient side, the Gallup and Palmer College 2018 report found that 16% of US adults had seen a chiropractor in the previous 12 months, so a new office mostly wins people who already use chiropractic care.

Education and the national boards

The degree. The Council on Chiropractic Education accredits Doctor of Chiropractic programs. Its directory listed 19 when checked in October 2026 and links each to “program completion rates and licensing board success rates”, worth reading before you enroll. The ACA describes the programs as four-year doctorates with “a minimum of 4,200 hours of classroom, laboratory and clinical internship.” Before the program, Texas and New York ask for 90 semester hours of college, and Florida requires a bachelor’s degree of anyone who enrolled in chiropractic college after July 1, 2000.

The NBCE exams. The National Board of Chiropractic Examiners runs the tests, but “the NBCE does not license/certify chiropractors” (NBCE); state boards decide what its scores are worth. Fees are from the NBCE fee schedule, as of October 2026.

Exam	What it covers	When you can sit it	Fee
Part I	Basic sciences: 255 questions across six domains, 375 to pass	Second year of the program	$710
Part II	Clinical sciences: 255 questions across six domains, 375 to pass	Third year	$710
Part III	80 multiple-choice questions, 20 extended cases and 30 diagnostic imaging sets	After Part I, within nine months of graduation	$710
Part IV	Practical: seven case management encounters, each followed by a written SOAP note, and a technique station of 10 adjustment setups	After Part I, within six months of graduation	$1,585
Physiotherapy	90 multiple-choice questions, after 120 hours of physiotherapy instruction	Once the hours are complete	$450

Part IV now runs at one NBCE assessment center in Greeley, Colorado, with appointments open up to six months ahead, and “October through December are the most popular months for testing”, so book as soon as you are eligible. Physiotherapy is called an elective, yet three of the four states below require it. Nor are the boards a formality: the NBCE reports part-level pass rates of 71% for Part I and 78% for Part II from January to July 2024.

One advertising trap starts here. Only people certified through the March 1983 administration may use the NBCE “Diplomate” title, and any other use in promotional materials “is misleading and confusing to the general public and is not permissible.”

State licenses: California, Texas, Florida and New York

No state accepts national board scores in place of its own license. The ACA describes state licensure as a requirement, and New York puts it plainly: “Any use of the title ‘Chiropractor’ within New York State requires licensure.” The table quotes each board’s own terms as of October 2026, and boards revise them, so check with yours before applying.

State	Agency	License	Key requirements, as the agency states them
California	Board of Chiropractic Examiners	Doctor of Chiropractic license, plus a Satellite Office Certificate for each additional location	NBCE Parts I to IV and physiotherapy. California Chiropractic Law Examination. Live Scan fingerprints. $345 application, $137 initial license, $336 annual renewal. 24 hours of continuing education a year
Texas	Texas Board of Chiropractic Examiners	Doctor of Chiropractic license	No reciprocity with any other state. 90 semester hours of college. NBCE Parts I to IV and physiotherapy. $200 nonrefundable processing fee, usually 30 days to process. Criminal background investigation. Texas Jurisprudence Examination, passed at 75% or better, $150
Florida	Board of Chiropractic Medicine	Chiropractic physician	Age 18. NBCE Parts I to IV and physiotherapy, plus the Florida Laws and Rules Examination. Electronic fingerprints. A certified National Practitioner Data Bank self-query. Verification of malpractice coverage. $405 in fees
New York	State Education Department, Office of the Professions	Chiropractor	Age 21 and good moral character. 90 semester hours with at least a 2.75 GPA, including 24 hours of life and physical science. NBCE Parts I to IV; physiotherapy not required. Child abuse identification training. $294 fee

California. Under 16 CCR 308, a chiropractor “with more than one place of practice shall obtain from the Board a Satellite Office Certificate for each additional place of practice”, renewed every year and displayed “in a conspicuous place.” The board’s fee schedule prices that certificate at $69, then $50 a year. The application packet warns that “standard processing time is three to five months.” Imaging in the office needs its own credential, since the state issues X-ray supervisor and operator permits to chiropractors (US Department of Labor license database).

Texas. “We DO NOT have reciprocity with any other” state, the board says. A chiropractor licensed elsewhere for at least three years with no disciplinary history may replace a missing NBCE part with the Special Purpose Exam for Chiropractors (SPEC). Since September 1, 2025, HB 4224 has required covered entities to post instructions for requesting records, contacting the licensing authority and filing a complaint, on the website and at the facility (bill text). The board’s summary notes that “a HIPAA Notice of Privacy Practices alone does not satisfy the requirement.”

Florida. Rule 64B2-17.009, adopted under Fla. Stat. 456.048, makes malpractice insurance or other proof of financial responsibility “a prerequisite for licensure or license renewal.” One way to meet it is coverage of “not less than $100,000 per claim, with a minimum annual aggregate of not less than $300,000.” The laws and rules exam now runs through the NBCE rather than the Department of Health, and the board’s licensing page says “an initial application must be reviewed within 30 days.”

New York. There is no physiotherapy exam, but Education Law section 6509-a “specifically prohibits fee splitting by licensees in the health professions of chiropractic” and several others (NYSED). Have any revenue-sharing deal with a landlord, marketer or fellow provider reviewed before you sign it.

In any other state, start at the state chiropractic board. Three of the four boards above add a law exam of their own to the NBCE scores.

NPI, Medicare and insurance credentialing

Credentialing often outlasts the build-out, so it starts the day the license number arrives.

The NPI. CMS calls it “a unique 10-digit number used to identify health care providers”, and every HIPAA-covered provider, “whether individuals or organizations, must obtain an NPI” (CMS). A provider is covered when it transmits health information electronically in connection with a covered transaction (45 CFR 160.103), which an office filing insurance claims electronically almost always does. In practice the doctor holds an individual NPI and the practice entity an organizational one.

Medicare enrollment. The CMS-855I lists “Chiropractic Medicine” among the physicians who enroll. The CMS Medicare Learning Network sets the order: “After you get an NPI, you can: Complete Medicare Program enrollment”, online through PECOS, which “sends the application electronically to your MAC”, the regional Medicare Administrative Contractor. Physicians “don’t pay a Medicare enrollment application fee”, and an associate who bills through your practice reassigns benefits to it on the same form.

No opting out. Chapter 15 of the Medicare Benefit Policy Manual is explicit: “The opt out law does not define ‘physician’ to include chiropractors; therefore, they may not opt out of Medicare and provide services under private contract.” A medical doctor can leave Medicare and contract privately with older patients; a chiropractor cannot. Any practice that will see Medicare patients needs a plan for them, insurance-based or not, so ask your Medicare Administrative Contractor how the rules apply to your setup before opening.

What Medicare pays for. Part B “only covers adjustments of the spine by a chiropractor to correct a subluxation”, by hand or with an activator, according to Medicare.gov, and it excludes “other services or tests a chiropractor orders, including X-rays, massage therapy, and acupuncture.” The CMS manual requires “an AT modifier on a claim when providing active/corrective treatment”, treats maintenance therapy as “not considered to be medically reasonable or necessary”, and describes the Advance Beneficiary Notice as what “allows a beneficiary to make an informed consumer decision” before care that may not be paid. Patients owe 20% after the Part B deductible, listed at $283 on Medicare.gov as of October 2026.

Commercial plans. Insurers commonly pull credentials from the CAQH Provider Data Portal, where “nearly two million providers actively enter and verify their information” through “a single credentialing application” that is “accepted or supported in all 50 states” (CAQH). The first profile “should take about two hours to complete.” In our experience each plan’s own review then takes months, so practices apply well before opening and rely on cash patients until approvals arrive.

Setting up the practice

Entity. The SBA says LLCs “protect you from personal liability in most instances”, while corporations give “the strongest protection” at a higher cost to form. California’s board charges $171 for a Chiropractic Corporation Certificate and $62 a year to renew it, and state law lets licensed chiropractors hold shares in a medical corporation as long as the listed non-physician licensees together own no more than 49 percent (Corporations Code 13401.5).

EIN. The IRS issues one online “in minutes for free.” Put the identical legal name on the state filing, the EIN, the NPI, the Medicare application and the CAQH profile; in our experience one stray word between those records can send an application back.

Insurance.

Malpractice. A license condition in Florida. Local Services Ads screening asks for “professional liability or medical malpractice insurance (provider)” and “general liability insurance (practice)” (Google), and insurers expect proof at credentialing.
Workers’ compensation. California requires employers to carry it “even if they have only one employee” (CSLB statement of California law). Texas employers “can choose” whether to, and “it is not required in most cases” (TDI). Florida’s threshold outside construction is “four or more employees” (Fla. Stat. 440.02), and in New York “virtually all employers” must provide it (NY Workers’ Compensation Board).
General liability, property and cyber. For the fall in the waiting room, the water-damaged table and the breached scheduling system.

Local permits. Before signing a lease, confirm the space is zoned for a medical office and which business license the city requires, and ask the state revenue department how front-desk sales of pillows or supplements are taxed.

Space, equipment and software

Working knowledge from practices we know, not a sourced list, with no prices because none could be verified.

Rooms. Reception, an exam room, adjusting rooms and, for active care, open floor for rehab. Tables are the core purchase, often a drop table and a flexion-distraction table first.
Modalities. Only where your state’s scope and your payers allow them.
X-ray. Your own unit, registered with the state and run by a credentialed operator, or referral to an imaging center; the NBCE notes that some practitioners “elect to use local radiology, laboratory, and other services.” Medicare will not pay for X-rays a chiropractor orders either way.
Software. An EHR with chiropractic SOAP notes, billing through a clearinghouse, online scheduling with text reminders, and phones that reach a person while the doctor is mid-adjustment.
Mobile. The 1% who practice from a vehicle trade the lease for a portable table; check where your board lets you treat.

Pricing, payers and cash flow

No source with a published method gives a typical visit fee or care-plan price, so none appears here. How each model gets paid:

Cash. Per-visit fees, prepaid care plans and memberships, priced by you.
Commercial insurance. Each plan’s contracted fees, beginning only once that plan approves you.
Medicare. Active manipulation only; maintenance is out of pocket, after the notice process above.
Personal injury. Paid at settlement or, in Florida, through personal injury protection, which pays medical benefits only if care begins “within 14 days after the motor vehicle accident” (Fla. Stat. 627.736). In our experience that money arrives months after the care.

Discounts carry rules too. California treats waiving deductibles or co-pays “when used as an advertising and/or marketing procedure” as unprofessional conduct “unless the insurer is notified in writing” (16 CCR 317).

Plan revenue per course of care rather than per visit: recent patients in Gallup’s 2015 study “visited a chiropractor an average of 11 times” in a year. No startup cost estimate we found met our sourcing standard, so price yours from quotes: build-out, tables, imaging, the EHR, premiums, exam and license fees, and cash for the months before insurers pay. The year’s rhythm of deductible resets and FSA deadlines is on our chiropractor marketing page.

Hiring and safety

Associates. About 2,800 new chiropractors enter the workforce each year (ACA). Each associate needs a state license and an individual NPI, and reassigns Medicare benefits to the practice.
Assistants. Oregon certifies chiropractic assistants through an exam the NBCE runs (NBCE state exams), and Florida’s board licenses a Certified Chiropractic Physician Assistant. Check your own board before posting the job.
Background checks. Boards run their own: Live Scan in California, electronic fingerprints in Florida, a criminal background investigation in Texas. Owners we know check front-desk hires as well, since they open patient records all day.
Radiation and privacy. An office X-ray unit answers to the state radiation program, and HIPAA training belongs in week one.

Finding the first patients

Recommendations. In the Gallup and Palmer College report, “seven out of 10 chiropractic patients (74%) say someone recommended chiropractic care to them before they went to a chiropractor for the first time.” For a new doctor, those recommenders tend to be nearby gyms and employers, plus the physical therapists, massage therapists and primary care offices that refer once they have read a few of the doctor’s notes.

Google Business Profile. It has to sit at a real, staffed treatment address. Google rules out a “virtual office”, and an office in a co-working space qualifies only if it “maintains clear signage, receives customers at the location during business hours, and is staffed during business hours by your business staff” (Google), which matters to a chiropractor renting one room in a shared wellness suite. In a multi-doctor office the practice keeps its own profile, and each public-facing doctor may have one under the doctor’s name alone. A practitioner profile may show “Dr.”, but Texas requires “doctor of chiropractic,” “D.C.,” “chiropractor” or “chiropractic” alongside any public use of it (22 TAC 77.3).

Local Services Ads. Google offers a Chiropractor category with the Google Verified badge. Screening covers provider and practice checks, general and professional liability insurance, state licenses where required, National Provider Identifier verification and a verified Business Profile, and “on average, this process takes 3-4 weeks” (Google). Pre-badge ads are unavailable to health care while screening runs (Google, leads), and its leads are calls only, with no message leads or call recordings (Google, lead types) and no lead credits (Google, credits). Google is moving Local Services Ads into Google Ads as “Performance Max campaigns with pay-per-lead goals”, home services first in August 2026 and every remaining category by 2027 (Google Ads Help). Apply once the license, the NPI and the malpractice policy are in hand.

Reviews. A new office opens with none, and BrightLocal’s 2026 survey found that 47% of consumers rule out a business with fewer than 20. The same survey found the share of consumers using AI tools for local recommendations rose “from 6% last year to 45%.” The FTC’s 2024 rule bans fake and bought reviews and lets the agency “seek civil penalties against knowing violators” (FTC), so ask every patient the same way and never pay for one.

Claims and solicitation. The FTC expects health benefit claims to rest on “competent and reliable scientific evidence” (Health Products Compliance Guidance), so sell access and convenience, never cures. Texas forbids a chiropractor’s written, phone or in-person solicitation about an accident until the 31st day after it (Texas Penal Code 38.12), and Florida allows only advertising directed to the public for the first 60 days after a crash (Fla. Stat. 817.234).

Our chiropractor marketing playbook goes further on each channel. For the profile itself, see Google Business Profile management, and for asking every patient, how we run review programs.

Where new chiropractic owners get caught out

Signing a lease before credentialing starts. NPI, PECOS, CAQH and each plan come first, or rent runs for months on cash patients alone.
Letting seniors think Medicare covers the care plan. It pays for active manipulation, never maintenance, and never X-rays a chiropractor orders.
Skipping the physiotherapy exam. California, Texas and Florida require it, and Texas offers no reciprocity to fix the gap later.
Opening a second California office on one license. Each additional location needs its own satellite certificate, renewed yearly.
Titles that break a rule. “Diplomate” belongs to pre-1983 certificate holders, and Texas never allows “Dr.” on its own.

Questions about starting a chiropractic practice

How long does it take to become a chiropractor?

Most people need three to four years of college and then a four-year Doctor of Chiropractic program of at least 4,200 hours. Texas and New York require 90 semester hours first, and Florida a bachelor’s degree for recent students. Board processing then runs about 30 days in Texas and three to five months in California.

Which NBCE exams do I need for a license?

You need Parts I to IV in all four states covered here, plus physiotherapy in California, Texas and Florida but not New York. Those three states also give a law exam of their own.

How much do the national boards cost?

All five NBCE exams cost $4,165 together, as of October 2026: $710 each for Parts I, II and III, $1,585 for Part IV and $450 for physiotherapy.

Can I move my chiropractic license to another state?

Not automatically. Texas has no reciprocity, though a chiropractor licensed elsewhere for three years with a clean record can cover missing NBCE parts with the SPEC exam. California’s fee schedule lists a $283 reciprocal license application, so each board sets its own route.

Do chiropractors have to accept Medicare?

Enrolling is a choice, but opting out is not: CMS says chiropractors “may not opt out of Medicare and provide services under private contract.” A practice that sees Medicare patients needs a plan for them either way.

Is it better to buy a practice or start one?

No published study compares the two with numbers, so weigh cash against time. Buying brings patients from the first week and can be financed with an SBA 7(a) loan of up to $5 million; starting costs less and fills the schedule more slowly.

How many patient visits does a typical practice handle?

The most common answer in the NBCE’s 2025 survey was 51 to 100 visits a week, given by 32% of chiropractors, who also reported spending about 7 hours a week on business management.

Sources

Checked on October 3, 2026. Rules and fees change, and many are set state by state or city by city: confirm the current requirements with the agency that issues them before you apply.

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