=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760256838
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLUMINATION CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2023
-----------------------------------------------------
Last Update Date | 11/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 690 N MAIN ST
-----------------------------------------------------
City | MOUNT ANGEL
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97362-9518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-599-2536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 690 N MAIN ST
-----------------------------------------------------
City | MOUNT ANGEL
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97362-9518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RACHEL MARIE KOHN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 971-599-2536
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------