Provider Demographics
NPI:1053634204
Name:MANGAN CHIROPRACTIC CLINIC, S.C.
Entity Type:Organization
Organization Name:MANGAN CHIROPRACTIC CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARLENE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MANGAN
Authorized Official - Suffix:
Authorized Official - Credentials:BS,DC, FIAMA
Authorized Official - Phone:309-797-4000
Mailing Address - Street 1:1510 48TH STREET PL
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3637
Mailing Address - Country:US
Mailing Address - Phone:309-797-4000
Mailing Address - Fax:309-797-5041
Practice Address - Street 1:1510 48TH STREET PL
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3637
Practice Address - Country:US
Practice Address - Phone:309-797-4000
Practice Address - Fax:309-797-5041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006108111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038006108Medicaid
IL08182055OtherBLUE CROSS BLUE SHIELD
IL204075Medicare PIN
IL038006108Medicaid