Provider Demographics
NPI:1003028127
Name:STATELINE CHIROPRACTIC & SPORTS INJURY CLINIC SC
Entity Type:Organization
Organization Name:STATELINE CHIROPRACTIC & SPORTS INJURY CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PROBST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-389-7870
Mailing Address - Street 1:1407 PATE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BELOIT
Mailing Address - State:IL
Mailing Address - Zip Code:61080-1431
Mailing Address - Country:US
Mailing Address - Phone:815-389-7870
Mailing Address - Fax:
Practice Address - Street 1:1407 PATE PLAZA DR
Practice Address - Street 2:
Practice Address - City:SOUTH BELOIT
Practice Address - State:IL
Practice Address - Zip Code:61080
Practice Address - Country:US
Practice Address - Phone:815-389-7870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008186111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038008186OtherLIC NUMBER