1528017217 NPI number — CHIROPRACTIC & SPINAL CARE CLINIC OF MASCOUTAH

Table of content: (NPI 1528017217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528017217 NPI number — CHIROPRACTIC & SPINAL CARE CLINIC OF MASCOUTAH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROPRACTIC & SPINAL CARE CLINIC OF MASCOUTAH
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:
1528017217
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:
13166 PRAIRIE GRASS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREESE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62230-4328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-420-0409
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 E CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MASCOUTAH
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62258-2110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-566-3500
Provider Business Practice Location Address Fax Number:
618-566-3500
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOLLENBAUGH
Authorized Official First Name:
JASON
Authorized Official Middle Name:
JAY
Authorized Official Title or Position:
PRESENDENT / OWNER
Authorized Official Telephone Number:
618-566-3500

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , 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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