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General NPI Number Information
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NPI Number | 1396008579
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Entity Type | Organization
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Legal Business Name | SPORTCHIRO, LLC
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Dates
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Enumeration Date | 06/21/2012
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Last Update Date | 06/21/2012
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Provider Practice Location Address
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Address Line | 1120 S STATE ROUTE 157 STE. 100
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-3786
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Country | US
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Telephone | 618-791-2983
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Fax |
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Provider Business Mailing Address
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Address Line | 1120 S STATE ROUTE 157 STE. 100
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-3786
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Country | US
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Telephone | 618-791-2983
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Fax |
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | DR. ERIC DOUGLAS DIXON
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Credential | DC
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Telephone | 618-791-2983
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 038012183
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License Number State | IL
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