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General NPI Number Information
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NPI Number | 1053616656
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Entity Type | Organization
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Legal Business Name | ELITECARE CENTER, LLC
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Dates
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Enumeration Date | 01/13/2011
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Last Update Date | 01/13/2011
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Provider Practice Location Address
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Address Line | 2870 N MAIN ST
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City | DECATUR
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State | IL
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Zip | 62526-3234
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Country | US
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Telephone | 217-877-8992
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Fax | 217-877-8978
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Provider Business Mailing Address
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Address Line | 2870 N MAIN ST
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City | DECATUR
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State | IL
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Zip | 62526-3234
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Country | US
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Telephone | 217-877-8992
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Fax | 217-877-8978
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Authorized Official
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Title or Position | EXECUTOR OF ESTATE
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Name | MRS. ROBIN RENEE NIEHAUS
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Credential |
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Telephone | 217-877-8992
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 344604179
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License Number State | IL
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