Provider Demographics
NPI:1043331036
Name:SOUTH ELGIN CHIROPRACTIC ASSOCIATES
Entity Type:Organization
Organization Name:SOUTH ELGIN CHIROPRACTIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-742-8900
Mailing Address - Street 1:1000 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-1466
Mailing Address - Country:US
Mailing Address - Phone:847-742-8900
Mailing Address - Fax:847-742-8905
Practice Address - Street 1:1000 W SPRING ST
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-1466
Practice Address - Country:US
Practice Address - Phone:847-742-8900
Practice Address - Fax:847-742-8905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004515230OtherBCBS
ILT38038Medicare UPIN
IL0004515230OtherBCBS
ILT38108Medicare UPIN
IL714100Medicare ID - Type Unspecified