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General NPI Number Information
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NPI Number | 1023556164
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Entity Type | Organization
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Legal Business Name | HEALTHSOURCE CHIROPRACTIC OF CHAMPAIGN, S.C.
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Dates
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Enumeration Date | 02/09/2017
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Last Update Date | 01/16/2018
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Provider Practice Location Address
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Address Line | 2003 ROUND BARN RD SUITE B
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City | CHAMPAIGN
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State | IL
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Zip | 61821-6827
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Country | US
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Telephone | 217-281-0006
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Fax |
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Provider Business Mailing Address
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Address Line | 2003 ROUND BARN RD SUITE B
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City | CHAMPAIGN
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State | IL
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Zip | 61821-6827
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Country | US
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Telephone | 217-281-0006
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CAMERON ROBERT MACKICHAN
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Credential | D.C.
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Telephone | 217-281-0006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 038.012800
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License Number State | IL
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