Healthcare Provider Details

I. General information

NPI: 1275954737
Provider Name (Legal Business Name): WEISS WELLNESS & CHIROPRACTIC, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2013
Last Update Date: 12/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 E FRONT ST
BLOOMINGTON IL
61701-5309
US

IV. Provider business mailing address

409 E FRONT ST
BLOOMINGTON IL
61701-5309
US

V. Phone/Fax

Practice location:
  • Phone: 309-828-3415
  • Fax: 309-828-2665
Mailing address:
  • Phone: 309-828-3415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038005425
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038005425
License Number StateIL

VIII. Authorized Official

Name: DR. MARY BEACH
Title or Position: PRESIDENT
Credential: D.C.
Phone: 309-828-3415