Healthcare Provider Details

I. General information

NPI: 1952356578
Provider Name (Legal Business Name): ANDREW W DYKEMAN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 08/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 EAST AIRLINE DRIVE
EAST ALTON IL
62024
US

IV. Provider business mailing address

33 EAST AIRLINE DRIVE
EAST ALTON IL
62024
US

V. Phone/Fax

Practice location:
  • Phone: 618-259-2676
  • Fax: 618-259-2679
Mailing address:
  • Phone: 618-259-2676
  • Fax: 618-259-2679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038010073
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: