Healthcare Provider Details

I. General information

NPI: 1083734537
Provider Name (Legal Business Name): KRISTOPHER M MCCLUSKY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 REGENCY CTR
COLLINSVILLE IL
62234-4659
US

IV. Provider business mailing address

410 REGENCY CTR
COLLINSVILLE IL
62234-4659
US

V. Phone/Fax

Practice location:
  • Phone: 618-343-3602
  • Fax:
Mailing address:
  • Phone: 618-343-3602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038010177
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: