Healthcare Provider Details

I. General information

NPI: 1770863649
Provider Name (Legal Business Name): ELITE CHIROPRACTIC AND REHABILITATION CENTER, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2011
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2422 E WASHINGTON ST SUITE 202
BLOOMINGTON IL
61704-4478
US

IV. Provider business mailing address

2422 E WASHINGTON ST SUITE 202
BLOOMINGTON IL
61704-4478
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-9900
  • Fax: 309-663-9901
Mailing address:
  • Phone: 309-663-9900
  • Fax: 309-663-9901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038009333
License Number StateIL

VIII. Authorized Official

Name: DR. ROBERT DENNIS BROWN
Title or Position: PRESIDENT/CEO
Credential: D.C.
Phone: 502-550-3120