Healthcare Provider Details

I. General information

NPI: 1487833992
Provider Name (Legal Business Name): BLOOMINGTON CHIROPRACTIC CENTER, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 S PROSPECT RD SUITE A
BLOOMINGTON IL
61704-4581
US

IV. Provider business mailing address

409 S PROSPECT RD SUITE A
BLOOMINGTON IL
61704-4581
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-8388
  • Fax: 309-663-0929
Mailing address:
  • Phone: 309-663-8388
  • Fax: 309-663-0929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number060002911- 038007235
License Number StateIL

VIII. Authorized Official

Name: DR. JOHN M EVERINGHAM
Title or Position: SENIOR ASSOICATE
Credential: D.C.
Phone: 309-663-8388