=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548645567
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDERSEN CHIROPRACTIC HEALTH, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2015
-----------------------------------------------------
Last Update Date | 07/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 606 N COUNTRY FAIR DR SUITE B
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61821-2496
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-351-1980
-----------------------------------------------------
Fax | 217-351-4070
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 606 N COUNTRY FAIR DR SUITE B
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61821-2496
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-351-1980
-----------------------------------------------------
Fax | 217-351-4070
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NORMAN D ANDERSEN JR.
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 217-351-1980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------