Healthcare Provider Details

I. General information

NPI: 1336148451
Provider Name (Legal Business Name): JACK DEE HOLLADA D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E BEARDSTOWN ST
VIRGINIA IL
62691-1304
US

IV. Provider business mailing address

200 E BEARDSTOWN ST
VIRGINIA IL
62691-1304
US

V. Phone/Fax

Practice location:
  • Phone: 217-452-7252
  • Fax:
Mailing address:
  • Phone: 217-452-7252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-004567
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH4004
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: