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General NPI Number Information
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NPI Number | 1346348802
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Entity Type | Organization
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Legal Business Name | WALTON CS-XVI PC
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 06/08/2012
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Provider Practice Location Address
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Address Line | 831 W JACKSON PLAZA
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City | MORTON
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State | IL
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Zip | 61550-1569
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Country | US
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Telephone | 309-263-5698
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Fax | 309-263-5697
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Provider Business Mailing Address
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Address Line | 831 W JACKSON PLAZA
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City | MORTON
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State | IL
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Zip | 61550-1569
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Country | US
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Telephone | 309-263-5698
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Fax | 309-263-5698
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Authorized Official
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Title or Position | OWNER
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Name | CHARLES JASON CARLIN
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Credential | DC
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Telephone | 309-263-5698
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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 | 038.012090
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License Number State | IL
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