Healthcare Provider Details

I. General information

NPI: 1467677179
Provider Name (Legal Business Name): JORDAHL CHIROPRACTIC & REHABILITATION CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 E GROVE AVE
RANTOUL IL
61866-2737
US

IV. Provider business mailing address

1640 E GROVE AVENUE
CHAMPAIGN IL
61866
US

V. Phone/Fax

Practice location:
  • Phone: 217-892-5770
  • Fax: 217-893-4316
Mailing address:
  • Phone: 217-892-5770
  • Fax: 217-893-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-006955
License Number StateIL

VIII. Authorized Official

Name: DR. DOUGLAS A JORDAHL
Title or Position: DOCTOR
Credential: D.C.
Phone: 217-892-5770