Healthcare Provider Details

I. General information

NPI: 1609126267
Provider Name (Legal Business Name): ROCK VALLEY CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 W WASHINGTON ST STE 115
OREGON IL
61061
US

IV. Provider business mailing address

1307 W WASHINGTON ST STE 115
OREGON IL
61061
US

V. Phone/Fax

Practice location:
  • Phone: 815-732-2826
  • Fax: 815-732-7617
Mailing address:
  • Phone: 815-732-2826
  • Fax: 815-732-7617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038011055
License Number StateIL

VIII. Authorized Official

Name: DR. KRANE T CUPPLES
Title or Position: OWNER
Credential: D.C.
Phone: 815-732-2826