1114111051 NPI number — DR. LEA A. CORNISH, P.C.

Table of content: (NPI 1114111051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114111051 NPI number — DR. LEA A. CORNISH, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. LEA A. CORNISH, P.C.
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:
CORNISH CHIROPRACTIC, LTD.
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:
1114111051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
624 W VETERANS PKWY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
YORKVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60560-2505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-385-6200
Provider Business Mailing Address Fax Number:
630-385-8526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 W VETERANS PKWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
YORKVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60560-2505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-385-6200
Provider Business Practice Location Address Fax Number:
630-385-8526
Provider Enumeration Date:
09/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CORNISH
Authorized Official First Name:
LEA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-385-6200

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038-007230 , 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: 02206815 . This is a "BC/BS #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 5162162 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1073680260 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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