Healthcare Provider Details

I. General information

NPI: 1760712350
Provider Name (Legal Business Name): FIRST CHOICE HEALTHCARE AND PHYSICAL MEDICINE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 N LOGAN ST
LINCOLN IL
62656-1741
US

IV. Provider business mailing address

714 N LOGAN ST
LINCOLN IL
62656-1741
US

V. Phone/Fax

Practice location:
  • Phone: 217-732-1111
  • Fax: 217-735-2744
Mailing address:
  • Phone: 217-732-1111
  • Fax: 217-735-2744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.007869
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.007886
License Number StateIL

VIII. Authorized Official

Name: DR. DAMON PAUL WALTON
Title or Position: DIRECTOR
Credential: DC
Phone: 217-732-1111