=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255641635
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIA CLINIC PAIN & INJURY RELIEF CENTER SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2010
-----------------------------------------------------
Last Update Date | 11/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 161 MARKET ST
-----------------------------------------------------
City | WILLOW SPRINGS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60480-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-649-2658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 161 MARKET ST
-----------------------------------------------------
City | WILLOW SPRINGS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60480-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-649-2658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OWNER
-----------------------------------------------------
Name | JOHN SPALLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-649-2658
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 038-008995
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------