Healthcare Provider Details

I. General information

NPI: 1588846190
Provider Name (Legal Business Name): ACCESS HEALTHCARE OF WATERLOO, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 N MARKET ST SUITE D
WATERLOO IL
62298-1079
US

IV. Provider business mailing address

742 N MARKET ST STE D P.O. BOX 423
WATERLOO IL
62298-1079
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-9850
  • Fax: 618-939-9860
Mailing address:
  • Phone: 618-939-9850
  • Fax: 618-939-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38010265
License Number StateIL

VIII. Authorized Official

Name: RODNEY A SMALL
Title or Position: PRESIDENT
Credential: DC
Phone: 618-327-3224