Healthcare Provider Details

I. General information

NPI: 1699956532
Provider Name (Legal Business Name): PREMIER CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 SUMMIT DR
STOCKTON IL
61085-9126
US

IV. Provider business mailing address

1615 SUMMIT DR
STOCKTON IL
61085-9126
US

V. Phone/Fax

Practice location:
  • Phone: 815-947-3320
  • Fax:
Mailing address:
  • Phone: 815-947-3320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. MIKE A WAMPFLER
Title or Position: OWNER/V.P.
Credential: D.C.
Phone: 815-947-3320