Healthcare Provider Details

I. General information

NPI: 1639019169
Provider Name (Legal Business Name): MT. VERNON CHIROPRACTIC CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2026
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 BROADWAY ST
MOUNT VERNON IL
62864-2202
US

IV. Provider business mailing address

3505 BROADWAY ST
MOUNT VERNON IL
62864-2202
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-4554
  • Fax: 618-242-4653
Mailing address:
  • Phone: 618-242-4554
  • Fax: 618-242-4653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TAMARA LYNN DRAKE
Title or Position: OFFICE MANAGER
Credential: RN
Phone: 618-242-4554