Healthcare Provider Details

I. General information

NPI: 1699842328
Provider Name (Legal Business Name): CLARK MICHAEL BUESCHER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 W. GLEN AVENUE
PEORIA IL
61614
US

IV. Provider business mailing address

1524 W. GLEN AVENUE
PEORIA IL
61614
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-3800
  • Fax: 309-692-4478
Mailing address:
  • Phone: 309-692-6800
  • Fax: 309-692-4478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-3404
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: