Healthcare Provider Details

I. General information

NPI: 1639128960
Provider Name (Legal Business Name): SPINALAID CENTER OF ILLINOIS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 E DEYOUNG ST SUITE 1
MARION IL
62959-2915
US

IV. Provider business mailing address

302 E DEYOUNG ST SUITE 1
MARION IL
62959-2915
US

V. Phone/Fax

Practice location:
  • Phone: 618-998-0000
  • Fax: 618-998-0001
Mailing address:
  • Phone: 618-998-0000
  • Fax: 618-998-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number038-005712
License Number StateIL

VIII. Authorized Official

Name: DR. KIRK ALEX PRICE
Title or Position: PRESIDENT
Credential: DC
Phone: 618-998-0000