Healthcare Provider Details

I. General information

NPI: 1245423748
Provider Name (Legal Business Name): BLY CHIROPRACTIC CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 E COLLEGE AVE STE C
BLOOMINGTON IL
61704-2484
US

IV. Provider business mailing address

2501 E COLLEGE AVE STE C
BLOOMINGTON IL
61704-2484
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-1155
  • Fax: 309-661-1043
Mailing address:
  • Phone: 309-661-1155
  • Fax: 309-661-1043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. TIMOTHY J BLY
Title or Position: CHIROPRACTOR/OWNER
Credential: D.C
Phone: 309-661-1155