Healthcare Provider Details

I. General information

NPI: 1568865707
Provider Name (Legal Business Name): FAIRBURY CHIROPRACTIC CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S CLAY ST
FAIRBURY IL
61739-1481
US

IV. Provider business mailing address

401 S CLAY ST
FAIRBURY IL
61739-1481
US

V. Phone/Fax

Practice location:
  • Phone: 815-692-2373
  • Fax: 815-692-2374
Mailing address:
  • Phone: 815-692-2373
  • Fax: 815-692-2374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038007108
License Number StateIL

VIII. Authorized Official

Name: DR. SCOTT J NOWAK
Title or Position: PRESIDENT
Credential: DC
Phone: 815-692-2373