=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699895201
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONROD CHIROPRACTIC CLINIC LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 03/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1802 DIVISION ST SUITE 211
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60450-1182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-941-2225
-----------------------------------------------------
Fax | 815-941-2785
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1802 DIVISION ST SUITE 211
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60450-1182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-941-2225
-----------------------------------------------------
Fax | 815-941-2785
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES.
-----------------------------------------------------
Name | DR. MARK ANDREW CONROD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-941-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038006182
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------