Healthcare Provider Details

I. General information

NPI: 1235415084
Provider Name (Legal Business Name): NICOLE MARIE HOMB D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 CYPRESS DR
COLONA IL
61241-9669
US

IV. Provider business mailing address

816 CYPRESS DR
COLONA IL
61241-9669
US

V. Phone/Fax

Practice location:
  • Phone: 309-737-8484
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038011663
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number007384
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: