=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861675217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDALUSIA FAMILY CHIROPRACTIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2007
-----------------------------------------------------
Last Update Date | 02/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 326 6TH AVE WEST SUITE 1
-----------------------------------------------------
City | ANDALUSIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61232-0555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-798-5555
-----------------------------------------------------
Fax | 309-798-5205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 326 6TH AVE WEST SUITE 1 PO BOX 555
-----------------------------------------------------
City | ANDALUSIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61232-0555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-798-5555
-----------------------------------------------------
Fax | 309-798-5205
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DOUGLAS BISBY
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 309-798-5555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038-010216
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 060-009615
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------