1629151675 NPI number — ADVANTAGE FAMILY CHIROPRACTIC LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629151675 NPI number — ADVANTAGE FAMILY CHIROPRACTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTAGE FAMILY CHIROPRACTIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629151675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2347 OLD COLLINSVILLE RD
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62221-3194
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-234-6000
Provider Business Mailing Address Fax Number:
618-234-6009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2347 OLD COLLINSVILLE RD
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62221-3194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-234-6000
Provider Business Practice Location Address Fax Number:
618-234-6009
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MEESE
Authorized Official First Name:
GAIL
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
DOCTOR OF CHIROPRACTIC
Authorized Official Telephone Number:
618-234-6000

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038-0100779 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7821832 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 769760 . This is a "HEALTH LINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 8557360 . This is a "CIGNA PPO" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 08232215 . This is a "BCBS IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1068318 . This is a "CIGNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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