Healthcare Provider Details

I. General information

NPI: 1376789545
Provider Name (Legal Business Name): SPINAL REHABILITATION AND WELLNESS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2008
Last Update Date: 12/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7177 CRIMSON RIDGE DR STE 7
ROCKFORD IL
61107-6235
US

IV. Provider business mailing address

7177 CRIMSON RIDGE DR STE 7
ROCKFORD IL
61107-6235
US

V. Phone/Fax

Practice location:
  • Phone: 815-227-9900
  • Fax: 815-227-9804
Mailing address:
  • Phone: 815-227-9900
  • Fax: 815-227-9804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038003512
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number038009573
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036037810
License Number StateIL

VIII. Authorized Official

Name: DR. DON HINDERLITER
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 815-227-9900