Healthcare Provider Details

I. General information

NPI: 1669722872
Provider Name (Legal Business Name): ICAN CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 S STATE ROUTE 157 STE 102
EDWARDSVILLE IL
62025-4017
US

IV. Provider business mailing address

441 S STATE ROUTE 157 STE 102
EDWARDSVILLE IL
62025-4017
US

V. Phone/Fax

Practice location:
  • Phone: 618-254-2273
  • Fax: 618-254-8476
Mailing address:
  • Phone: 618-254-2273
  • Fax: 618-254-8476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.12178
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MICHAEL S HARBISON
Title or Position: OWNER/DIRECTOR
Credential: DC
Phone: 618-254-2273