=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083003446
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOLWIS HEALTH CENTERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2015
-----------------------------------------------------
Last Update Date | 01/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 W HIGHWAY 50
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-235-2097
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 705 W HIGHWAY 50
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GREG KOMESHAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 865-235-2097
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2320
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------