Provider Demographics
NPI:1083912190
Name:HURST CHIROPRACTIC
Entity Type:Organization
Organization Name:HURST CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:HURST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-762-8803
Mailing Address - Street 1:4820 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3675
Mailing Address - Country:US
Mailing Address - Phone:309-762-2273
Mailing Address - Fax:309-762-8867
Practice Address - Street 1:4820 22ND AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3675
Practice Address - Country:US
Practice Address - Phone:309-762-2273
Practice Address - Fax:309-762-8867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0038004345111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0038004345Medicaid
IL0038004345Medicaid