=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154432193
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAGE FAMILY CHIROPRACTIC CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 12/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 N JACKSON
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-446-7200
-----------------------------------------------------
Fax | 217-446-0090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 N JACKSON
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-446-7200
-----------------------------------------------------
Fax | 217-446-0090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT CHIROPRACTOR
-----------------------------------------------------
Name | DR. GARY DEAN PAGE JR.
-----------------------------------------------------
Credential | CHIROPRACTOR
-----------------------------------------------------
Telephone | 217-446-7200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038009157
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038005681
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------