MEDICARE: VIBRANT HEALTH CHIROPRACTIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1053874024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIBRANT HEALTH CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	411 SOUTH RD
Second Line	:
City	:	CAMBRIDGE
State	:	IL
Zip	:	61238-1402
Country	:	US
Telephone Number	:	309-714-3483
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 SOUTH RD
Second Line	:
City	:	CAMBRIDGE
State	:	IL
Zip	:	61238-1402
Country	:	US
Telephone Number	:	309-714-3483
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CRYSTAL JAYNE STRODE
Credential	:	DC
Telephone Number	:	309-714-3483

Provider Enumeration Date	:	04/08/2019
Last Update Date	:	04/08/2019

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