Healthcare Provider Details

I. General information

NPI: 1750685046
Provider Name (Legal Business Name): DANIELLE VAHLKAMP PHARMD., D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2011
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 N POPLAR ST
CENTRALIA IL
62801-3234
US

IV. Provider business mailing address

2324 S 3RD ST
FAYETTEVILLE IL
62258-5052
US

V. Phone/Fax

Practice location:
  • Phone: 618-532-4158
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.011845
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038.011845
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2019035654
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051302298
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: