=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902337223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PFLUG FAMILY CHIROPRACTIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2017
-----------------------------------------------------
Last Update Date | 03/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 CORN SILK LN
-----------------------------------------------------
City | DIVERNON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62530-9728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-971-7433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 CORN SILK LN
-----------------------------------------------------
City | DIVERNON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62530-9728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. IAN GRANT PFLUG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-971-7433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38013010
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------