Healthcare Provider Details

I. General information

NPI: 1639189178
Provider Name (Legal Business Name): RICHIE CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 WABASH AVE SUITE 107
SPRINGFIELD IL
62704-5354
US

IV. Provider business mailing address

2205 WABASH AVE SUITE 107
SPRINGFIELD IL
62704-5354
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-1311
  • Fax: 217-698-7504
Mailing address:
  • Phone: 217-698-1311
  • Fax: 217-698-7504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038008580
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070014190
License Number StateIL

VIII. Authorized Official

Name: DR. LOREN WILLIAMS RICHIE
Title or Position: PRESIDENT
Credential: DC
Phone: 217-698-1311