Provider Demographics
NPI:1073880423
Name:UPPER CERVICAL CARE OF ALTON LLC
Entity Type:Organization
Organization Name:UPPER CERVICAL CARE OF ALTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WYNNDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUENGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-465-7177
Mailing Address - Street 1:3 PROFESSIONAL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5067
Mailing Address - Country:US
Mailing Address - Phone:618-465-7177
Mailing Address - Fax:
Practice Address - Street 1:3 PROFESSIONAL DR
Practice Address - Street 2:SUITE B
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5067
Practice Address - Country:US
Practice Address - Phone:618-465-7177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PIASA PAIN CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008971261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL569760Medicare PIN
ILU78729Medicare UPIN