Provider Demographics
NPI:1073612180
Name:CHILDS, CALLEN R (DC)
Entity Type:Individual
Prefix:DR
First Name:CALLEN
Middle Name:R
Last Name:CHILDS
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 1:1605 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611
Mailing Address - Country:US
Mailing Address - Phone:309-698-7010
Mailing Address - Fax:309-698-7065
Practice Address - Street 1:1605 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611
Practice Address - Country:US
Practice Address - Phone:309-698-7010
Practice Address - Fax:309-698-7065
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
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
667760Medicare ID - Type Unspecified