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General NPI Number Information
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NPI Number | 1467668574
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Entity Type | Organization
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Legal Business Name | WYATT CHIROPRACTIC CLINIC, LTD
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Dates
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Enumeration Date | 05/15/2007
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Last Update Date | 10/13/2011
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Provider Practice Location Address
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Address Line | 731 S WEST ST
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City | OLNEY
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State | IL
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Zip | 62450
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Country | US
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Telephone | 618-392-5511
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Fax |
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Provider Business Mailing Address
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Address Line | 731 S WEST ST PO BOX 96
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City | OLNEY
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State | IL
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Zip | 62450
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Country | US
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Telephone | 618-392-5511
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | DR. RONALD JAY GREENBERG
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Credential | D.C.
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Telephone | 618-392-5511
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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 | 038004748
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License Number State | IL
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