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General NPI Number Information
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NPI Number | 1437249158
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Entity Type | Organization
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Legal Business Name | KOMESHAK CHIROPRACTIC LTD
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Dates
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Enumeration Date | 10/13/2006
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Last Update Date | 02/25/2011
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Provider Practice Location Address
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Address Line | 3030 FRANK SCOTT PKWY W SUITE 1
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City | BELLEVILLE
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State | IL
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Zip | 62223-5014
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Country | US
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Telephone | 618-236-3600
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Fax | 618-236-3600
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Provider Business Mailing Address
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Address Line | 3030 FRANK SCOTT PKWY W SUITE 1
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City | BELLEVILLE
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State | IL
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Zip | 62223-5014
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Country | US
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Telephone | 618-236-3600
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Fax | 618-236-3600
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Authorized Official
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Title or Position | OWNER
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Name | PATRICK KOMESHAK
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Credential | DC
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Telephone | 618-236-3600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070011807
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 038008047
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License Number State | IL
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