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General NPI Number Information
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NPI Number | 1265714307
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Entity Type | Organization
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Legal Business Name | GREEN CHIROPRACTIC PC
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Dates
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Enumeration Date | 09/14/2011
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Last Update Date | 09/14/2011
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Provider Practice Location Address
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Address Line | 400 BROADWAY ST
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City | GALENA
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State | IL
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Zip | 61036
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Country | US
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Telephone | 815-777-0042
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Fax |
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Provider Business Mailing Address
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Address Line | 1736 HWY 80 S.
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City | CUBA CITY
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State | WI
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Zip | 53807
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JASON M GREEN
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Credential | D.C.
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Telephone | 563-209-8583
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 038011965
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License Number State | IL
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