=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205476108
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM H. NORTHERN DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2020
-----------------------------------------------------
Last Update Date | 02/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 SOUTH MAIN ST. SUITE A
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62236-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-719-2350
-----------------------------------------------------
Fax | 618-234-8295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1005 SOUTH MAIN ST. SUITE A
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62236-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-719-2350
-----------------------------------------------------
Fax | 618-234-8295
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038.013521
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------