MEDICARE: TAYLORVILLE CHIROPRACTIC CLINIC LTD.

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	038006559	IL

General Provider Information

NPI Number	:	1063491389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAYLORVILLE CHIROPRACTIC CLINIC LTD.

Provider Business Mailing Address
First Line	:	2339 PONTOON ROAD
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040
Country	:	US
Telephone Number	:	618-931-2050
Fax Number	:	314-895-5040

Provider Business Practice Location Address
First Line	:	2339 PONTOON ROAD
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040
Country	:	US
Telephone Number	:	618-931-2050
Fax Number	:	314-895-5040

Authorized Official
Title or Position	:	PRESIDENT OF CORPORATION
Name	:	DR. PHILIP S DUDAK
Credential	:	DC
Telephone Number	:	618-931-2050

Provider Enumeration Date	:	01/13/2006
Last Update Date	:	07/22/2008

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