Healthcare Provider Details

I. General information

NPI: 1295790830
Provider Name (Legal Business Name): MT. CARMEL CHIROPRACTIC CLINIC, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 N MARKET ST
MOUNT CARMEL IL
62863-1459
US

IV. Provider business mailing address

616 N MARKET ST
MOUNT CARMEL IL
62863-1459
US

V. Phone/Fax

Practice location:
  • Phone: 618-262-2225
  • Fax: 618-262-2880
Mailing address:
  • Phone: 618-262-2225
  • Fax: 618-262-2880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number042-617767
License Number StateIL

VIII. Authorized Official

Name: DR. VIRGIL LEE POTTS
Title or Position: PRESIDENT
Credential: D.C.
Phone: 618-262-2225