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General NPI Number Information
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NPI Number | 1346790342
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Entity Type | Organization
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Legal Business Name | SELVIDGE CHIROPRACTIC
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Dates
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Enumeration Date | 10/13/2016
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Last Update Date | 10/13/2016
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Provider Practice Location Address
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Address Line | 608 BROADWAY AVE
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City | MATTOON
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State | IL
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Zip | 61938-4321
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Country | US
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Telephone | 217-235-4664
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Fax |
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Provider Business Mailing Address
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Address Line | 608 BROADWAY AVE
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City | MATTOON
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State | IL
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Zip | 61938-4321
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Country | US
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Telephone | 217-235-4664
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Fax |
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. WILLIAM SELVIDGE
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Credential | D.C.
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Telephone | 217-235-4664
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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 | 038008622
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License Number State | IL
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