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General NPI Number Information
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NPI Number | 1639318173
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Entity Type | Organization
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Legal Business Name | PETERSBURG SPINE & SPORT INC
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Dates
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Enumeration Date | 02/06/2009
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Last Update Date | 01/05/2015
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Provider Practice Location Address
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Address Line | 115 E DOUGLAS AVE
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City | PETERSBURG
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State | IL
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Zip | 62675-1558
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Country | US
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Telephone | 217-632-7599
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Fax |
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Provider Business Mailing Address
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Address Line | 115 E DOUGLAS AVE
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City | PETERSBURG
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State | IL
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Zip | 62675-1558
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Country | US
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Telephone | 217-632-7599
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. MICHAEL GENSLER
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Credential | DC
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Telephone | 217-632-7599
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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 | 038011323
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License Number State | IL
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