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General NPI Number Information
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NPI Number | 1285830133
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Entity Type | Organization
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Legal Business Name | MIDWEST SPINE AND REHAB CORP
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Dates
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Enumeration Date | 06/26/2007
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Last Update Date | 11/23/2007
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Provider Practice Location Address
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Address Line | 705 W US HIGHWAY 50
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City | O FALLON
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State | IL
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Zip | 62269-1900
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Country | US
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Telephone | 618-624-4242
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Fax |
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Provider Business Mailing Address
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Address Line | 705 W US HIGHWAY 50
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City | O FALLON
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State | IL
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Zip | 62269-1900
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Country | US
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Telephone | 618-624-4242
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. GREG SCOTT KOMESHAK
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Credential | D.C
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Telephone | 618-624-4242
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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 | 38009537
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License Number State | IL
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