Healthcare Provider Details

I. General information

NPI: 1275524241
Provider Name (Legal Business Name): GALENA CHIROPRACTIC CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BROADWAY ST
GALENA IL
61036-1902
US

IV. Provider business mailing address

400 BROADWAY ST
GALENA IL
61036-1902
US

V. Phone/Fax

Practice location:
  • Phone: 815-777-0042
  • Fax:
Mailing address:
  • Phone: 815-777-0042
  • Fax: 815-777-0043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARK DOUGLAS NEWCOMER
Title or Position: PRESIDENT OWNER
Credential: DC
Phone: 815-777-0042