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General NPI Number Information
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NPI Number | 1205231131
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Entity Type | Organization
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Legal Business Name | CRAIG SPINE AND SPORT, LLC
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Dates
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Enumeration Date | 11/04/2014
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Last Update Date | 11/04/2014
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Provider Practice Location Address
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Address Line | 330 S MAIN ST SUITE E
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City | MORTON
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State | IL
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Zip | 61550-1976
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Country | US
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Telephone | 309-360-2137
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Fax |
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Provider Business Mailing Address
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Address Line | 330 S MAIN ST SUITE E
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City | MORTON
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State | IL
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Zip | 61550-1976
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Country | US
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Telephone | 309-360-2137
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR/OWNER
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Name | DR. MATTHEW CARL CRAIG
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Credential | D.C.
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Telephone | 309-360-2137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 038011215
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License Number State | IL
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