Healthcare Provider Details

I. General information

NPI: 1790806636
Provider Name (Legal Business Name): BUSHNELL CHIROPRACTIC CENTER SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 COLE ST
BUSHNELL IL
61422-1540
US

IV. Provider business mailing address

448 COLE ST
BUSHNELL IL
61422-1540
US

V. Phone/Fax

Practice location:
  • Phone: 309-772-2317
  • Fax: 309-772-2317
Mailing address:
  • Phone: 309-772-2317
  • Fax: 309-772-2317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. KRISTOPHER WADE WAKEFIELD
Title or Position: OWNER
Credential: DC
Phone: 309-772-2317