1982613584 NPI number — INTEGRATIVE CHIROPRACTIC & SPORTS MEDICINE, LTD

Table of content: (NPI 1982613584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982613584 NPI number — INTEGRATIVE CHIROPRACTIC & SPORTS MEDICINE, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATIVE CHIROPRACTIC & SPORTS MEDICINE, LTD
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:
INTEGRATIVE SPINAL & SPORTS REHABILITATION
Provider Other Organization Name Type Code:
3
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:
1982613584
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13520 S. ROUTE 59
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
PLAINFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-439-9800
Provider Business Mailing Address Fax Number:
815-439-9804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13520 S. ROUTE 59
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PLAINFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-439-9800
Provider Business Practice Location Address Fax Number:
815-439-9804
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EASTERDAY
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER/CHIROPRACTOR
Authorized Official Telephone Number:
815-439-9800

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038009675 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 038.009675 , 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)





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