1669722872 NPI number — ICAN CLINIC LLC

Table of content: ZACHARY BEAU JONES PA-C (NPI 1861021552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669722872 NPI number — ICAN CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ICAN CLINIC 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:
WOOD RIVER CHIROPRACTIC
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:
1669722872
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
441 S STATE ROUTE 157 STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDWARDSVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62025-4017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-254-2273
Provider Business Mailing Address Fax Number:
618-254-8476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
441 S STATE ROUTE 157 STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDWARDSVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62025-4017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-254-2273
Provider Business Practice Location Address Fax Number:
618-254-8476
Provider Enumeration Date:
09/14/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HARBISON
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
618-254-2273

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038.12178 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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