Healthcare Provider Details

I. General information

NPI: 1841299815
Provider Name (Legal Business Name): TIMOTHY J. BLY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 E COLLEGE AVE
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: 309-585-0704
  • Fax: 309-661-1043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038005081
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: