Healthcare Provider Details

I. General information

NPI: 1750421194
Provider Name (Legal Business Name): WATERLOO MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 04/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

966 S LIBRARY ST
WATERLOO IL
62298-1484
US

IV. Provider business mailing address

966 S LIBRARY ST
WATERLOO IL
62298-1484
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-7400
  • Fax: 618-939-7434
Mailing address:
  • Phone: 618-939-7400
  • Fax: 618-939-7434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number038-007391
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-036716
License Number StateIL

VIII. Authorized Official

Name: DR. JOHN H. NOBBE
Title or Position: CLINIC DIRECTOR
Credential: DC
Phone: 618-939-7400