1285854877 NPI number — DAVIDSON CHIROPRACTIC CLINIC PC

Table of content: LISA ANN MILETO CRNA (NPI 1710955042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285854877 NPI number — DAVIDSON CHIROPRACTIC CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVIDSON CHIROPRACTIC CLINIC PC
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:
1285854877
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1640 WILLOW CIRCLE DR
Provider Second Line Business Mailing Address:
STE # 400
Provider Business Mailing Address City Name:
CREST HILL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60435-0959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-729-9922
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1640 WILLOW CIRCLE DR
Provider Second Line Business Practice Location Address:
STE # 400
Provider Business Practice Location Address City Name:
CREST HILL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-729-9922
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIDSON
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
815-729-9922

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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