Provider Demographics
NPI:1063505071
Name:ANDERSON, ERIC WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:WAYNE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:1310 N IL RT 251
Mailing Address - City:LOSTANT
Mailing Address - State:IL
Mailing Address - Zip Code:61334
Mailing Address - Country:US
Mailing Address - Phone:815-368-3421
Mailing Address - Fax:815-368-3404
Practice Address - Street 1:1310 N IL RT 251
Practice Address - Street 2:
Practice Address - City:LOSTANT
Practice Address - State:IL
Practice Address - Zip Code:61334
Practice Address - Country:US
Practice Address - Phone:815-368-3421
Practice Address - Fax:815-368-3404
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL573040Medicare ID - Type Unspecified