Healthcare Provider Details

I. General information

NPI: 1316773666
Provider Name (Legal Business Name): KOAH CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S WEBER RD STE 9A
ROMEOVILLE IL
60446-5065
US

IV. Provider business mailing address

600 S WEBER RD STE 9
ROMEOVILLE IL
60446-5065
US

V. Phone/Fax

Practice location:
  • Phone: 815-293-3000
  • Fax:
Mailing address:
  • Phone: 815-293-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: KENNETH ROSS ELLUL
Title or Position: OWNER/PROVIDER
Credential: D.C.
Phone: 815-293-3000