Healthcare Provider Details

I. General information

NPI: 1942395926
Provider Name (Legal Business Name): DAWN M SAMPLE DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N MAIN ST
MANTENO IL
60950-1534
US

IV. Provider business mailing address

51 N MAIN ST
MANTENO IL
60950-1534
US

V. Phone/Fax

Practice location:
  • Phone: 815-468-8403
  • Fax: 815-468-0154
Mailing address:
  • Phone: 815-468-8403
  • Fax: 815-468-0154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: