Healthcare Provider Details

I. General information

NPI: 1831469998
Provider Name (Legal Business Name): BLEEM FAMILY CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2012
Last Update Date: 01/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 W MAIN ST
HAVANA IL
62644-1140
US

IV. Provider business mailing address

314 W MAIN ST
HAVANA IL
62644-1140
US

V. Phone/Fax

Practice location:
  • Phone: 309-543-4341
  • Fax: 309-543-4321
Mailing address:
  • Phone: 309-543-4341
  • Fax: 309-543-4321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038007902
License Number StateIL

VIII. Authorized Official

Name: DR. RENOLD B BLEEM
Title or Position: OWNER
Credential: DC
Phone: 309-543-4341